| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
575 |
572 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
12 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
120 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
377 |
377 |
$2K |
| D0330 |
Panoramic radiographic image |
105 |
105 |
$2K |
| D0272 |
Bitewings - two radiographic images |
248 |
247 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
138 |
137 |
$859.13 |
| D0220 |
Intraoral - periapical first radiographic image |
96 |
95 |
$802.62 |
| D0210 |
Intraoral - complete series of radiographic images |
63 |
63 |
$0.00 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$0.00 |