| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
86 |
50 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
67 |
$15K |
| D2950 |
|
77 |
54 |
$12K |
| D1110 |
Prophylaxis - adult |
161 |
161 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
207 |
207 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
252 |
252 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
109 |
109 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
31 |
$4K |
| D1120 |
Prophylaxis - child |
92 |
92 |
$4K |
| D1206 |
Topical application of fluoride varnish |
141 |
141 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
29 |
$502.01 |