| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
670 |
376 |
$53K |
| D2740 |
Crown - porcelain/ceramic |
98 |
93 |
$47K |
| D1110 |
Prophylaxis - adult |
768 |
768 |
$42K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
352 |
258 |
$35K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
51 |
48 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
673 |
673 |
$20K |
| D0274 |
Bitewings - four radiographic images |
721 |
721 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
310 |
310 |
$8K |
| D1120 |
Prophylaxis - child |
165 |
165 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
265 |
265 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
264 |
264 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
46 |
46 |
$2K |
| D0272 |
Bitewings - two radiographic images |
108 |
108 |
$2K |
| D2394 |
|
13 |
13 |
$2K |
| D2331 |
|
16 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
57 |
57 |
$750.12 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$420.00 |