| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
269 |
154 |
$128K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
411 |
411 |
$27K |
| D4341 |
|
294 |
83 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
351 |
351 |
$17K |
| D4910 |
|
196 |
196 |
$15K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
124 |
59 |
$14K |
| D1110 |
Prophylaxis - adult |
145 |
144 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
183 |
106 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
166 |
77 |
$9K |
| D3320 |
|
18 |
15 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
80 |
52 |
$6K |
| D9430 |
|
187 |
174 |
$6K |
| D1320 |
|
365 |
365 |
$6K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
219 |
219 |
$3K |
| D0350 |
|
340 |
135 |
$3K |
| D1120 |
Prophylaxis - child |
33 |
33 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
405 |
214 |
$2K |
| D4342 |
|
37 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
87 |
85 |
$1K |
| D0274 |
Bitewings - four radiographic images |
48 |
48 |
$950.40 |