| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
1,048 |
1,001 |
$204.99 |
| D0220 |
Intraoral - periapical first radiographic image |
1,902 |
1,818 |
$50.96 |
| D0270 |
|
621 |
595 |
$17.45 |
| D0330 |
Panoramic radiographic image |
1,073 |
1,047 |
$0.00 |
| D1110 |
Prophylaxis - adult |
359 |
346 |
$0.00 |
| D1120 |
Prophylaxis - child |
267 |
254 |
$0.00 |
| D1354 |
|
1,496 |
560 |
$0.00 |
| D0191 |
|
197 |
189 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
728 |
711 |
$0.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
41 |
27 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
16 |
$0.00 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
20 |
15 |
$0.00 |
| D4910 |
|
13 |
13 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
378 |
369 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
510 |
495 |
$0.00 |
| D1351 |
Sealant - per tooth |
281 |
160 |
$0.00 |
| D1330 |
|
864 |
840 |
$0.00 |
| D0170 |
|
164 |
151 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,770 |
985 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
712 |
689 |
$0.00 |
| D0601 |
|
362 |
355 |
$0.00 |
| D0603 |
|
551 |
531 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
379 |
181 |
$0.00 |
| D0602 |
|
200 |
191 |
$0.00 |
| D2331 |
|
20 |
14 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
55 |
$0.00 |
| D4355 |
|
15 |
15 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
41 |
37 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
20 |
19 |
$0.00 |