| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
393 |
388 |
$24K |
| D9430 |
|
549 |
482 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
263 |
258 |
$12K |
| D0350 |
|
103 |
99 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
23 |
12 |
$3K |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
108 |
108 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
98 |
93 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
233 |
170 |
$947.70 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$540.00 |