| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
56 |
32 |
$46K |
| D2950 |
|
137 |
86 |
$20K |
| D0330 |
Panoramic radiographic image |
112 |
112 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
192 |
192 |
$10K |
| D3320 |
|
15 |
13 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
67 |
67 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
12 |
$3K |
| D1110 |
Prophylaxis - adult |
31 |
31 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
13 |
$2K |