| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
145 |
145 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
326 |
89 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
241 |
85 |
$33K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
165 |
66 |
$29K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
195 |
76 |
$22K |
| D7240 |
Removal of impacted tooth - completely bony |
57 |
26 |
$17K |
| D9222 |
|
144 |
144 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
186 |
185 |
$9K |
| D2330 |
|
59 |
30 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
99 |
99 |
$6K |
| D7230 |
|
21 |
14 |
$5K |
| D0330 |
Panoramic radiographic image |
90 |
90 |
$4K |
| D1110 |
Prophylaxis - adult |
44 |
44 |
$3K |
| D0274 |
Bitewings - four radiographic images |
79 |
79 |
$2K |
| D1206 |
Topical application of fluoride varnish |
68 |
68 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
140 |
140 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
106 |
106 |
$879.04 |