| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
361 |
361 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
249 |
249 |
$12K |
| D1351 |
Sealant - per tooth |
154 |
41 |
$6K |
| D1120 |
Prophylaxis - child |
128 |
127 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
69 |
45 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
23 |
12 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
174 |
174 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
399 |
99 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$168.00 |