| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
666 |
129 |
$172K |
| D9222 |
|
151 |
129 |
$98K |
| D1110 |
Prophylaxis - adult |
284 |
257 |
$21K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
159 |
44 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
30 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
316 |
281 |
$4K |
| D9310 |
|
65 |
64 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
25 |
$2K |
| D1330 |
|
214 |
187 |
$820.25 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$695.50 |
| D0120 |
Periodic oral evaluation - established patient |
72 |
67 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
77 |
72 |
$0.00 |