| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
1,023 |
398 |
$485K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
904 |
892 |
$59K |
| D2954 |
|
551 |
245 |
$57K |
| D4341 |
|
531 |
142 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
778 |
777 |
$37K |
| D1110 |
Prophylaxis - adult |
307 |
306 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
420 |
128 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
295 |
133 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
203 |
48 |
$16K |
| D0350 |
|
1,479 |
388 |
$14K |
| D9430 |
|
252 |
233 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
67 |
33 |
$8K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
15 |
13 |
$7K |
| D3320 |
|
20 |
14 |
$7K |
| D4910 |
|
69 |
69 |
$5K |
| D1320 |
|
288 |
287 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
156 |
156 |
$2K |
| D1206 |
Topical application of fluoride varnish |
109 |
109 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
117 |
113 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
226 |
83 |
$937.58 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$630.00 |