| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
390 |
121 |
$311K |
| D2950 |
|
352 |
126 |
$48K |
| D0330 |
Panoramic radiographic image |
780 |
780 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
780 |
780 |
$34K |
| D3310 |
|
28 |
13 |
$22K |
| D1110 |
Prophylaxis - adult |
421 |
421 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
176 |
90 |
$19K |
| D0274 |
Bitewings - four radiographic images |
591 |
591 |
$18K |
| D3320 |
|
17 |
13 |
$16K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
13 |
12 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
99 |
57 |
$13K |
| D4342 |
|
62 |
17 |
$12K |
| D0350 |
|
248 |
244 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
273 |
273 |
$8K |
| D1206 |
Topical application of fluoride varnish |
314 |
314 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
437 |
431 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
117 |
117 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
70 |
70 |
$2K |
| D1120 |
Prophylaxis - child |
50 |
50 |
$2K |