| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,318 |
1,318 |
$65K |
| D0330 |
Panoramic radiographic image |
1,062 |
1,062 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,151 |
1,151 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,568 |
1,568 |
$39K |
| D0220 |
Intraoral - periapical first radiographic image |
2,295 |
2,272 |
$27K |
| D7240 |
Removal of impacted tooth - completely bony |
100 |
40 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
304 |
161 |
$23K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
235 |
102 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
439 |
435 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
386 |
386 |
$9K |
| D9222 |
|
53 |
53 |
$5K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
48 |
48 |
$4K |
| D7230 |
|
18 |
12 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
15 |
$2K |
| D1206 |
Topical application of fluoride varnish |
27 |
27 |
$441.60 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$417.60 |