| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
952 |
927 |
$33K |
| D1120 |
Prophylaxis - child |
587 |
584 |
$26K |
| D0274 |
Bitewings - four radiographic images |
799 |
782 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
860 |
830 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
236 |
137 |
$21K |
| D0330 |
Panoramic radiographic image |
352 |
347 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
633 |
624 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
487 |
484 |
$14K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
123 |
24 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,030 |
964 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
194 |
193 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
91 |
56 |
$7K |
| D2394 |
|
37 |
26 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
467 |
372 |
$5K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
16 |
15 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
59 |
$3K |
| D9222 |
|
15 |
14 |
$1K |
| D1320 |
|
200 |
198 |
$809.77 |