| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
1,152 |
805 |
$24K |
| D0330 |
Panoramic radiographic image |
791 |
559 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
926 |
557 |
$16K |
| D1120 |
Prophylaxis - child |
952 |
572 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
137 |
78 |
$10K |
| D1351 |
Sealant - per tooth |
348 |
33 |
$8K |
| D0272 |
Bitewings - two radiographic images |
752 |
420 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
517 |
300 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
314 |
233 |
$2K |
| D1206 |
Topical application of fluoride varnish |
88 |
81 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$1K |