| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
134 |
134 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
115 |
115 |
$3K |
| D0330 |
Panoramic radiographic image |
51 |
51 |
$3K |
| D0274 |
Bitewings - four radiographic images |
88 |
88 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
43 |
43 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
34 |
34 |
$633.76 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$486.00 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
28 |
$332.04 |