| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
989 |
989 |
$48K |
| D0274 |
Bitewings - four radiographic images |
1,074 |
1,074 |
$29K |
| D0330 |
Panoramic radiographic image |
462 |
462 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
913 |
913 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
348 |
347 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
314 |
314 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
972 |
961 |
$12K |
| D7240 |
Removal of impacted tooth - completely bony |
39 |
12 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
756 |
740 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
312 |
312 |
$5K |
| D9222 |
|
53 |
53 |
$5K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
53 |
53 |
$5K |
| D1206 |
Topical application of fluoride varnish |
259 |
259 |
$4K |
| D1120 |
Prophylaxis - child |
78 |
78 |
$3K |