| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
242 |
241 |
$16K |
| D1120 |
Prophylaxis - child |
230 |
229 |
$11K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
272 |
146 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
44 |
27 |
$2K |
| D2160 |
|
33 |
24 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
44 |
$883.62 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$874.41 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$289.64 |
| D0120 |
Periodic oral evaluation - established patient |
366 |
365 |
$142.70 |
| D2140 |
|
15 |
12 |
$78.84 |
| D0274 |
Bitewings - four radiographic images |
155 |
154 |
$63.61 |
| D0220 |
Intraoral - periapical first radiographic image |
133 |
131 |
$34.82 |
| D0230 |
Intraoral - periapical each additional radiographic image |
72 |
24 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
401 |
399 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
12 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
138 |
129 |
$0.00 |