| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
257 |
100 |
$218K |
| D4341 |
|
233 |
63 |
$56K |
| D0350 |
|
270 |
270 |
$54K |
| D2950 |
|
213 |
106 |
$29K |
| D2991 |
|
377 |
82 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
129 |
64 |
$18K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
16 |
14 |
$18K |
| D0330 |
Panoramic radiographic image |
267 |
267 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
216 |
216 |
$12K |
| D0460 |
|
378 |
347 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
29 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
126 |
120 |
$6K |
| D0274 |
Bitewings - four radiographic images |
167 |
167 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
16 |
$3K |
| D0380 |
|
19 |
19 |
$3K |
| D1110 |
Prophylaxis - adult |
21 |
21 |
$2K |
| D1206 |
Topical application of fluoride varnish |
18 |
18 |
$755.28 |