| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
428 |
267 |
$199K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
209 |
179 |
$95K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,003 |
1,003 |
$66K |
| D0210 |
Intraoral - complete series of radiographic images |
861 |
861 |
$41K |
| D2954 |
|
373 |
251 |
$39K |
| D9430 |
|
279 |
269 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
764 |
371 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
26 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
233 |
226 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
23 |
17 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
15 |
$2K |
| D1206 |
Topical application of fluoride varnish |
32 |
32 |
$500.50 |
| D0350 |
|
182 |
55 |
$456.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$168.00 |
| D1330 |
|
72 |
72 |
$0.00 |