| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
590 |
562 |
$488.16 |
| D1110 |
Prophylaxis - adult |
381 |
344 |
$389.40 |
| D0120 |
Periodic oral evaluation - established patient |
558 |
512 |
$293.79 |
| D1206 |
Topical application of fluoride varnish |
1,557 |
1,510 |
$282.63 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
134 |
105 |
$247.88 |
| D0220 |
Intraoral - periapical first radiographic image |
1,150 |
1,098 |
$214.04 |
| D1351 |
Sealant - per tooth |
1,574 |
483 |
$140.00 |
| D0191 |
|
821 |
817 |
$126.00 |
| D0274 |
Bitewings - four radiographic images |
313 |
293 |
$84.96 |
| D7140 |
Extraction, erupted tooth or exposed root |
54 |
25 |
$30.49 |
| D0270 |
|
104 |
95 |
$29.28 |
| D1120 |
Prophylaxis - child |
277 |
273 |
$22.98 |
| D0230 |
Intraoral - periapical each additional radiographic image |
618 |
514 |
$21.12 |
| D1330 |
|
511 |
509 |
$0.00 |
| D1310 |
|
412 |
411 |
$0.00 |
| D9310 |
|
59 |
59 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
203 |
203 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
41 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
15 |
$0.00 |
| D0190 |
|
214 |
206 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
25 |
$0.00 |
| D1354 |
|
256 |
45 |
$0.00 |