| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
877 |
875 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,247 |
1,244 |
$35K |
| D0274 |
Bitewings - four radiographic images |
661 |
660 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
168 |
152 |
$17K |
| D1120 |
Prophylaxis - child |
363 |
362 |
$16K |
| D9310 |
|
72 |
72 |
$8K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
17 |
17 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
376 |
374 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
17 |
17 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
90 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
174 |
172 |
$2K |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$442.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$154.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$126.00 |