| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
509 |
274 |
$59K |
| D9430 |
|
996 |
957 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
312 |
312 |
$21K |
| D0330 |
Panoramic radiographic image |
357 |
357 |
$11K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
17 |
14 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,156 |
516 |
$5K |
| D1110 |
Prophylaxis - adult |
37 |
37 |
$3K |
| D1120 |
Prophylaxis - child |
63 |
63 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
189 |
186 |
$2K |
| D0274 |
Bitewings - four radiographic images |
82 |
82 |
$2K |
| D3221 |
|
14 |
14 |
$882.00 |
| D1206 |
Topical application of fluoride varnish |
36 |
36 |
$567.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$182.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |