| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
677 |
677 |
$44K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
215 |
81 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
477 |
477 |
$23K |
| D2740 |
Crown - porcelain/ceramic |
40 |
28 |
$19K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
41 |
35 |
$19K |
| D1110 |
Prophylaxis - adult |
194 |
194 |
$17K |
| D3320 |
|
40 |
30 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
197 |
80 |
$13K |
| D0330 |
Panoramic radiographic image |
301 |
301 |
$9K |
| D3310 |
|
22 |
12 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
91 |
24 |
$5K |
| D4341 |
|
39 |
13 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
249 |
123 |
$2K |
| D0274 |
Bitewings - four radiographic images |
87 |
87 |
$2K |
| D0350 |
|
19 |
12 |
$393.60 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$193.00 |