| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7240 |
Removal of impacted tooth - completely bony |
2,551 |
1,480 |
$679K |
| D9310 |
|
4,390 |
4,386 |
$232K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
2,453 |
2,350 |
$210K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
2,189 |
1,557 |
$170K |
| D9222 |
|
2,285 |
2,280 |
$107K |
| D0330 |
Panoramic radiographic image |
3,751 |
3,751 |
$107K |
| D0367 |
|
135 |
135 |
$35K |
| D1120 |
Prophylaxis - child |
511 |
510 |
$17K |
| D7230 |
|
74 |
69 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
822 |
820 |
$8K |
| D9610 |
|
775 |
774 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
300 |
299 |
$7K |
| D1206 |
Topical application of fluoride varnish |
242 |
241 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
442 |
437 |
$5K |
| D9430 |
|
402 |
398 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
278 |
278 |
$3K |
| D1354 |
|
213 |
56 |
$3K |
| D0272 |
Bitewings - two radiographic images |
117 |
117 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
83 |
83 |
$918.40 |
| D9110 |
|
55 |
55 |
$699.72 |
| D0240 |
|
50 |
26 |
$600.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$336.00 |
| D0602 |
|
17 |
17 |
$17.00 |