| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
219 |
134 |
$497.90 |
| D1206 |
Topical application of fluoride varnish |
4,890 |
4,691 |
$271.13 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
266 |
206 |
$186.40 |
| D0140 |
Limited oral evaluation - problem focused |
789 |
764 |
$173.45 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
886 |
866 |
$161.47 |
| D0210 |
Intraoral - complete series of radiographic images |
222 |
213 |
$100.83 |
| D1120 |
Prophylaxis - child |
1,206 |
1,158 |
$94.35 |
| D1110 |
Prophylaxis - adult |
749 |
695 |
$81.78 |
| D0220 |
Intraoral - periapical first radiographic image |
917 |
888 |
$60.82 |
| D0274 |
Bitewings - four radiographic images |
638 |
621 |
$56.62 |
| D0120 |
Periodic oral evaluation - established patient |
471 |
458 |
$43.06 |
| D1354 |
|
4,050 |
615 |
$42.27 |
| D0708 |
|
993 |
415 |
$12.00 |
| D0191 |
|
1,669 |
1,637 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
106 |
86 |
$0.00 |
| D4910 |
|
12 |
12 |
$0.00 |
| D0270 |
|
25 |
25 |
$0.00 |
| D1999 |
|
22 |
22 |
$0.00 |
| D0707 |
|
66 |
23 |
$0.00 |
| D2940 |
|
32 |
18 |
$0.00 |
| D0603 |
|
2,624 |
2,498 |
$0.00 |
| D1310 |
|
3,970 |
3,743 |
$0.00 |
| D1330 |
|
4,619 |
4,327 |
$0.00 |
| D0703 |
|
4,528 |
853 |
$0.00 |
| D9995 |
|
323 |
299 |
$0.00 |
| D0602 |
|
505 |
500 |
$0.00 |
| D1355 |
|
5,983 |
685 |
$0.00 |
| D0601 |
|
241 |
240 |
$0.00 |
| D1351 |
Sealant - per tooth |
1,131 |
235 |
$0.00 |
| D0240 |
|
149 |
72 |
$0.00 |
| D0706 |
|
142 |
77 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
246 |
122 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
42 |
40 |
$0.00 |
| D9992 |
|
14 |
14 |
$0.00 |
| D0709 |
|
27 |
25 |
$0.00 |