| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
400 |
174 |
$9K |
| D0330 |
Panoramic radiographic image |
505 |
424 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
438 |
361 |
$2K |
| D1110 |
Prophylaxis - adult |
161 |
129 |
$750.86 |
| D0250 |
|
286 |
243 |
$551.86 |
| D1120 |
Prophylaxis - child |
189 |
159 |
$500.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
210 |
176 |
$480.00 |
| D0140 |
Limited oral evaluation - problem focused |
119 |
90 |
$451.60 |
| D1351 |
Sealant - per tooth |
83 |
19 |
$308.00 |
| D0120 |
Periodic oral evaluation - established patient |
105 |
88 |
$187.88 |
| T1015 |
Clinic visit/encounter, all-inclusive |
933 |
724 |
$0.00 |