| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
480 |
121 |
$175K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
157 |
145 |
$107K |
| D1110 |
Prophylaxis - adult |
1,274 |
1,176 |
$61K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
106 |
46 |
$56K |
| D2950 |
|
348 |
169 |
$55K |
| D0140 |
Limited oral evaluation - problem focused |
519 |
501 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
800 |
742 |
$17K |
| D3320 |
|
31 |
26 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
344 |
332 |
$13K |
| D0274 |
Bitewings - four radiographic images |
318 |
308 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
130 |
126 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
444 |
423 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
18 |
$5K |
| D2954 |
|
26 |
13 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
16 |
$4K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$780.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$715.00 |