| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
182 |
113 |
$86K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
505 |
505 |
$33K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
54 |
46 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
476 |
476 |
$22K |
| D2952 |
|
105 |
70 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
152 |
78 |
$10K |
| D1110 |
Prophylaxis - adult |
93 |
93 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
32 |
$3K |
| D9430 |
|
105 |
100 |
$3K |
| D0350 |
|
108 |
36 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
62 |
59 |
$732.00 |
| D1206 |
Topical application of fluoride varnish |
42 |
42 |
$700.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
84 |
61 |
$376.65 |
| D1208 |
Topical application of fluoride, excluding varnish |
21 |
21 |
$313.00 |