| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
194 |
107 |
$51K |
| D1110 |
Prophylaxis - adult |
601 |
596 |
$21K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
28 |
27 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
162 |
69 |
$19K |
| D9610 |
|
1,248 |
1,098 |
$18K |
| D2950 |
|
123 |
75 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
135 |
54 |
$12K |
| D0274 |
Bitewings - four radiographic images |
556 |
549 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
414 |
397 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,210 |
1,114 |
$9K |
| D4355 |
|
93 |
93 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
479 |
476 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
184 |
77 |
$3K |
| D2394 |
|
21 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
289 |
219 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
149 |
136 |
$1K |
| D4910 |
|
25 |
25 |
$968.64 |
| D9630 |
|
13 |
13 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$0.00 |