| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,299 |
836 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
805 |
797 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,162 |
1,150 |
$5K |
| D1120 |
Prophylaxis - child |
1,587 |
1,567 |
$4K |
| D1206 |
Topical application of fluoride varnish |
3,552 |
3,524 |
$4K |
| D1110 |
Prophylaxis - adult |
1,284 |
1,282 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
2,480 |
2,460 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
926 |
898 |
$3K |
| D4910 |
|
828 |
825 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
2,548 |
2,471 |
$2K |
| D0274 |
Bitewings - four radiographic images |
1,425 |
1,413 |
$2K |
| D4341 |
|
80 |
36 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,308 |
1,944 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
134 |
99 |
$840.00 |
| D0330 |
Panoramic radiographic image |
898 |
886 |
$520.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
149 |
101 |
$448.00 |
| D0603 |
|
630 |
609 |
$266.00 |
| D0270 |
|
197 |
187 |
$154.00 |
| D1999 |
|
135 |
120 |
$119.00 |
| D0602 |
|
566 |
555 |
$110.00 |
| D0272 |
Bitewings - two radiographic images |
64 |
64 |
$100.00 |
| D4921 |
|
480 |
198 |
$0.00 |
| D1351 |
Sealant - per tooth |
51 |
12 |
$0.00 |
| D1330 |
|
53 |
53 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
27 |
26 |
$0.00 |
| D0601 |
|
16 |
16 |
$0.00 |