| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
578 |
412 |
$274K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
195 |
178 |
$90K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,340 |
1,340 |
$88K |
| D0210 |
Intraoral - complete series of radiographic images |
1,345 |
1,345 |
$65K |
| D0350 |
|
4,393 |
1,145 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
215 |
125 |
$14K |
| D2954 |
|
137 |
109 |
$14K |
| D3320 |
|
34 |
28 |
$12K |
| D2330 |
|
139 |
36 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
174 |
86 |
$9K |
| D1110 |
Prophylaxis - adult |
106 |
106 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
95 |
45 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
41 |
27 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
184 |
184 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
59 |
12 |
$238.95 |