| Code | Description | Claims | Beneficiaries | Total Paid |
| D0140 |
Limited oral evaluation - problem focused |
82 |
66 |
$50.00 |
| D0220 |
Intraoral - periapical first radiographic image |
199 |
157 |
$38.00 |
| D1206 |
Topical application of fluoride varnish |
119 |
101 |
$0.00 |
| D0603 |
|
414 |
329 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
240 |
180 |
$0.00 |
| D1310 |
|
326 |
279 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
150 |
65 |
$0.00 |
| D1330 |
|
1,289 |
894 |
$0.00 |
| D1320 |
|
105 |
90 |
$0.00 |
| D9995 |
|
169 |
166 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
98 |
72 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
24 |
$0.00 |
| D1355 |
|
730 |
27 |
$0.00 |
| D0602 |
|
18 |
15 |
$0.00 |
| D0191 |
|
417 |
343 |
$0.00 |
| D1321 |
|
42 |
33 |
$0.00 |
| D1110 |
Prophylaxis - adult |
51 |
46 |
$0.00 |
| D1354 |
|
1,488 |
75 |
$0.00 |
| D9996 |
|
29 |
29 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
13 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
36 |
32 |
$0.00 |
| D0330 |
Panoramic radiographic image |
31 |
28 |
$0.00 |