| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
2,554 |
960 |
$197K |
| D9243 |
|
617 |
598 |
$93K |
| D7240 |
Removal of impacted tooth - completely bony |
257 |
108 |
$58K |
| D0330 |
Panoramic radiographic image |
1,299 |
1,297 |
$42K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
209 |
202 |
$30K |
| D9239 |
|
300 |
295 |
$22K |
| D9310 |
|
619 |
619 |
$16K |
| D0160 |
|
460 |
460 |
$12K |
| D9222 |
|
100 |
95 |
$6K |
| D7230 |
|
18 |
12 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
116 |
115 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
28 |
28 |
$204.91 |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
30 |
$172.31 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$162.80 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$75.79 |
| D9612 |
|
241 |
234 |
$0.00 |