| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
475 |
432 |
$0.00 |
| D1110 |
Prophylaxis - adult |
392 |
391 |
$0.00 |
| D1120 |
Prophylaxis - child |
22 |
22 |
$0.00 |
| D0330 |
Panoramic radiographic image |
324 |
322 |
$0.00 |
| D2332 |
|
86 |
47 |
$0.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
153 |
88 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
312 |
130 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
365 |
364 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
485 |
410 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
97 |
96 |
$0.00 |
| D1351 |
Sealant - per tooth |
494 |
86 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
207 |
121 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
356 |
355 |
$0.00 |
| D1330 |
|
101 |
100 |
$0.00 |
| D2335 |
|
138 |
58 |
$0.00 |
| D2330 |
|
53 |
27 |
$0.00 |
| D4355 |
|
52 |
52 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
303 |
303 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
110 |
55 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
17 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
567 |
356 |
$0.00 |
| D2331 |
|
22 |
13 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$0.00 |