| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
1,455 |
1,217 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,007 |
894 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
181 |
180 |
$11K |
| D1110 |
Prophylaxis - adult |
1,190 |
1,056 |
$9K |
| D1330 |
|
1,680 |
1,506 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
118 |
81 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,471 |
1,316 |
$1K |
| D1351 |
Sealant - per tooth |
251 |
47 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
101 |
41 |
$1K |
| D9110 |
|
74 |
53 |
$279.32 |
| D0220 |
Intraoral - periapical first radiographic image |
123 |
118 |
$261.14 |
| D1120 |
Prophylaxis - child |
39 |
39 |
$56.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
26 |
$0.00 |
| D2335 |
|
48 |
12 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$0.00 |