| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
794 |
791 |
$206K |
| D0140 |
Limited oral evaluation - problem focused |
854 |
822 |
$132K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
632 |
622 |
$123K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
803 |
546 |
$110K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
426 |
293 |
$59K |
| D7140 |
Extraction, erupted tooth or exposed root |
348 |
184 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
68 |
49 |
$11K |
| D0330 |
Panoramic radiographic image |
306 |
301 |
$128.92 |
| D0274 |
Bitewings - four radiographic images |
1,038 |
1,030 |
$101.53 |
| D1110 |
Prophylaxis - adult |
1,396 |
1,381 |
$84.66 |
| D0220 |
Intraoral - periapical first radiographic image |
672 |
647 |
$17.41 |
| D1206 |
Topical application of fluoride varnish |
788 |
783 |
$14.99 |
| D9910 |
|
114 |
100 |
$0.00 |
| D1120 |
Prophylaxis - child |
46 |
46 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
64 |
27 |
$0.00 |
| D4355 |
|
13 |
12 |
$0.00 |
| D1351 |
Sealant - per tooth |
49 |
12 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$0.00 |
| D1330 |
|
17 |
16 |
$0.00 |