| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
210 |
191 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
26 |
14 |
$2K |
| D0330 |
Panoramic radiographic image |
53 |
52 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
15 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
79 |
66 |
$2K |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$434.84 |
| D0120 |
Periodic oral evaluation - established patient |
17 |
17 |
$242.76 |
| D1999 |
|
118 |
95 |
$0.00 |