| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
307 |
182 |
$146K |
| D0350 |
|
6,406 |
1,104 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
331 |
330 |
$22K |
| D2954 |
|
190 |
117 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
275 |
130 |
$18K |
| D1110 |
Prophylaxis - adult |
200 |
200 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
303 |
303 |
$14K |
| D4341 |
|
197 |
52 |
$14K |
| D9430 |
|
293 |
234 |
$9K |
| D4910 |
|
114 |
114 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
102 |
55 |
$8K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
16 |
13 |
$7K |
| D3221 |
|
123 |
71 |
$7K |
| D0330 |
Panoramic radiographic image |
264 |
254 |
$7K |
| D9110 |
|
99 |
86 |
$6K |
| D1206 |
Topical application of fluoride varnish |
324 |
323 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,271 |
458 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
136 |
122 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
14 |
$1K |
| D2940 |
|
21 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
62 |
61 |
$928.80 |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$915.00 |
| D0272 |
Bitewings - two radiographic images |
79 |
78 |
$156.00 |
| D1330 |
|
22 |
21 |
$0.00 |