| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,303 |
1,296 |
$108K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
733 |
730 |
$42K |
| D4341 |
|
156 |
54 |
$11K |
| D2330 |
|
98 |
49 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
526 |
520 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
632 |
438 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
38 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
21 |
12 |
$2K |
| D9110 |
|
27 |
26 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
32 |
$1K |
| D2920 |
|
13 |
12 |
$546.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
12 |
$144.00 |