| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
3,889 |
593 |
$430K |
| D7240 |
Removal of impacted tooth - completely bony |
1,111 |
378 |
$213K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
1,166 |
1,065 |
$117K |
| D9239 |
|
905 |
903 |
$113K |
| D9243 |
|
1,060 |
823 |
$98K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
653 |
598 |
$81K |
| D1120 |
Prophylaxis - child |
374 |
368 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
293 |
290 |
$10K |
| D1110 |
Prophylaxis - adult |
202 |
201 |
$9K |
| D9610 |
|
341 |
341 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
417 |
411 |
$8K |
| D0274 |
Bitewings - four radiographic images |
239 |
239 |
$7K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$1K |
| 0001A |
|
19 |
19 |
$950.56 |
| 0002A |
|
17 |
17 |
$925.30 |
| D9612 |
|
33 |
33 |
$0.00 |