| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
305 |
106 |
$137K |
| D2950 |
|
254 |
94 |
$37K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
214 |
60 |
$34K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
48 |
39 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
315 |
315 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
210 |
210 |
$9K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$930.00 |
| D1206 |
Topical application of fluoride varnish |
17 |
17 |
$120.00 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$60.50 |
| D9630 |
|
94 |
56 |
$0.00 |