| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D5226 |
|
93 |
93 |
$58K |
| D2740 |
Crown - porcelain/ceramic |
113 |
68 |
$55K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
485 |
260 |
$52K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
378 |
217 |
$51K |
| D0210 |
Intraoral - complete series of radiographic images |
497 |
497 |
$33K |
| D5225 |
|
49 |
49 |
$31K |
| D2950 |
|
217 |
131 |
$30K |
| D1110 |
Prophylaxis - adult |
611 |
611 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
551 |
551 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
606 |
606 |
$16K |
| D1206 |
Topical application of fluoride varnish |
521 |
521 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
163 |
100 |
$14K |
| D1120 |
Prophylaxis - child |
315 |
315 |
$13K |
| D2394 |
|
90 |
56 |
$13K |
| D0274 |
Bitewings - four radiographic images |
289 |
289 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
55 |
28 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
432 |
428 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
615 |
331 |
$6K |
| D1351 |
Sealant - per tooth |
121 |
31 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
65 |
65 |
$3K |