| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,328 |
2,328 |
$116K |
| D7240 |
Removal of impacted tooth - completely bony |
367 |
103 |
$103K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
617 |
467 |
$86K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
838 |
519 |
$68K |
| D0140 |
Limited oral evaluation - problem focused |
1,384 |
1,379 |
$51K |
| D0274 |
Bitewings - four radiographic images |
1,823 |
1,823 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,430 |
1,430 |
$30K |
| D0330 |
Panoramic radiographic image |
552 |
552 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
645 |
645 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
272 |
181 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,577 |
1,555 |
$20K |
| D9222 |
|
200 |
200 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
91 |
63 |
$9K |
| D9310 |
|
144 |
144 |
$9K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
71 |
71 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
70 |
58 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
191 |
191 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
53 |
53 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
47 |
47 |
$488.81 |