| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
79 |
54 |
$44K |
| D1110 |
Prophylaxis - adult |
299 |
299 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
165 |
165 |
$7K |
| D0330 |
Panoramic radiographic image |
105 |
105 |
$6K |
| D2950 |
|
34 |
27 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
27 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
36 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
106 |
106 |
$3K |