| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
91 |
82 |
$590.94 |
| D0220 |
Intraoral - periapical first radiographic image |
855 |
800 |
$399.78 |
| D0120 |
Periodic oral evaluation - established patient |
3,981 |
3,952 |
$259.86 |
| D1120 |
Prophylaxis - child |
2,772 |
2,763 |
$257.88 |
| D0230 |
Intraoral - periapical each additional radiographic image |
74 |
74 |
$197.39 |
| D1206 |
Topical application of fluoride varnish |
3,611 |
3,584 |
$146.16 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
398 |
391 |
$124.28 |
| D0272 |
Bitewings - two radiographic images |
961 |
956 |
$119.55 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
419 |
194 |
$92.80 |
| D1110 |
Prophylaxis - adult |
1,196 |
1,179 |
$52.80 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
208 |
190 |
$26.40 |
| D1320 |
|
243 |
232 |
$0.00 |
| D1351 |
Sealant - per tooth |
158 |
44 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
268 |
262 |
$0.00 |
| D1999 |
|
97 |
94 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
408 |
403 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
191 |
94 |
$0.00 |
| D0330 |
Panoramic radiographic image |
44 |
42 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
52 |
12 |
$0.00 |