| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
258 |
87 |
$161K |
| D2954 |
|
121 |
63 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
263 |
87 |
$17K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
15 |
12 |
$11K |
| D1110 |
Prophylaxis - adult |
193 |
183 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
196 |
186 |
$8K |
| D2950 |
|
41 |
14 |
$7K |
| D0274 |
Bitewings - four radiographic images |
169 |
164 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
257 |
241 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
78 |
74 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
190 |
176 |
$2K |
| D1120 |
Prophylaxis - child |
28 |
26 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
39 |
38 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
13 |
$801.00 |
| D0120 |
Periodic oral evaluation - established patient |
33 |
33 |
$785.00 |