| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
856 |
798 |
$173.45 |
| D0210 |
Intraoral - complete series of radiographic images |
56 |
55 |
$41.98 |
| D1110 |
Prophylaxis - adult |
265 |
256 |
$40.89 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
596 |
558 |
$40.49 |
| D0220 |
Intraoral - periapical first radiographic image |
881 |
827 |
$31.14 |
| D0602 |
|
199 |
187 |
$25.00 |
| D1206 |
Topical application of fluoride varnish |
838 |
772 |
$14.40 |
| D1999 |
|
908 |
748 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
31 |
$0.00 |
| D4341 |
|
63 |
25 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
173 |
165 |
$0.00 |
| D1120 |
Prophylaxis - child |
45 |
45 |
$0.00 |
| D4910 |
|
14 |
14 |
$0.00 |
| D1330 |
|
2,014 |
1,748 |
$0.00 |
| D0603 |
|
141 |
131 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
165 |
125 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
137 |
124 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
44 |
26 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
15 |
$0.00 |