| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,230 |
2,230 |
$67K |
| D0210 |
Intraoral - complete series of radiographic images |
1,346 |
1,346 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,608 |
1,608 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
848 |
845 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
417 |
417 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
300 |
300 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
27 |
$2K |
| D0330 |
Panoramic radiographic image |
59 |
59 |
$2K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
13 |
13 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
13 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
72 |
72 |
$759.55 |
| D9222 |
|
13 |
13 |
$739.05 |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
24 |
$258.90 |