| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
236 |
37 |
$173K |
| D2950 |
|
224 |
46 |
$41K |
| D1351 |
Sealant - per tooth |
398 |
49 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
276 |
273 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
173 |
172 |
$12K |
| D1110 |
Prophylaxis - adult |
100 |
100 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
12 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
136 |
135 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
73 |
73 |
$2K |
| D1120 |
Prophylaxis - child |
46 |
46 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$571.10 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$220.13 |