| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
731 |
417 |
$347K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,584 |
1,584 |
$104K |
| D2954 |
|
619 |
358 |
$65K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
137 |
112 |
$63K |
| D0210 |
Intraoral - complete series of radiographic images |
1,189 |
1,186 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
623 |
623 |
$47K |
| D1120 |
Prophylaxis - child |
823 |
823 |
$38K |
| D4910 |
|
408 |
406 |
$31K |
| D9430 |
|
427 |
405 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,333 |
1,317 |
$14K |
| D1110 |
Prophylaxis - adult |
151 |
151 |
$14K |
| D1206 |
Topical application of fluoride varnish |
720 |
720 |
$12K |
| D3320 |
|
32 |
25 |
$12K |
| D0274 |
Bitewings - four radiographic images |
544 |
544 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
154 |
85 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
477 |
477 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
48 |
25 |
$6K |
| D4341 |
|
52 |
14 |
$4K |
| D4342 |
|
56 |
16 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$300.00 |
| D0350 |
|
24 |
13 |
$211.20 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$156.00 |