| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9222 |
|
458 |
433 |
$92K |
| D7240 |
Removal of impacted tooth - completely bony |
316 |
97 |
$57K |
| D0160 |
|
1,338 |
1,249 |
$51K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
424 |
154 |
$40K |
| D1999 |
|
1,179 |
1,065 |
$19K |
| D0330 |
Panoramic radiographic image |
180 |
179 |
$5K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
12 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
104 |
103 |
$1K |
| D9995 |
|
106 |
104 |
$1K |
| D1120 |
Prophylaxis - child |
18 |
18 |
$360.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
19 |
19 |
$281.77 |
| D0120 |
Periodic oral evaluation - established patient |
15 |
15 |
$231.30 |