| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,083 |
2,083 |
$102K |
| D0330 |
Panoramic radiographic image |
1,384 |
1,380 |
$69K |
| D0140 |
Limited oral evaluation - problem focused |
1,824 |
1,793 |
$66K |
| D0274 |
Bitewings - four radiographic images |
1,989 |
1,989 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
2,295 |
2,295 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
986 |
985 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,258 |
2,257 |
$37K |
| D1120 |
Prophylaxis - child |
1,026 |
1,025 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
263 |
167 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,636 |
1,571 |
$20K |
| D2394 |
|
162 |
101 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
339 |
316 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
117 |
84 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
36 |
25 |
$5K |
| D2161 |
|
32 |
12 |
$4K |
| D2160 |
|
35 |
24 |
$3K |
| D0272 |
Bitewings - two radiographic images |
104 |
104 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
23 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
12 |
$144.82 |