| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
406 |
277 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
182 |
98 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
432 |
293 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
221 |
157 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
115 |
100 |
$4K |
| D1120 |
Prophylaxis - child |
253 |
183 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
156 |
128 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
187 |
127 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
29 |
$1K |
| D1351 |
Sealant - per tooth |
52 |
13 |
$946.00 |
| D1206 |
Topical application of fluoride varnish |
117 |
106 |
$910.02 |
| D0274 |
Bitewings - four radiographic images |
180 |
154 |
$818.32 |
| D0220 |
Intraoral - periapical first radiographic image |
148 |
106 |
$385.00 |
| D0272 |
Bitewings - two radiographic images |
51 |
35 |
$300.00 |
| T1015 |
Clinic visit/encounter, all-inclusive |
611 |
550 |
$0.00 |