| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
557 |
555 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
395 |
393 |
$18K |
| D1120 |
Prophylaxis - child |
201 |
201 |
$10K |
| D1110 |
Prophylaxis - adult |
104 |
104 |
$9K |
| D2740 |
Crown - porcelain/ceramic |
14 |
13 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
90 |
90 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
28 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
280 |
280 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
24 |
13 |
$3K |
| D1351 |
Sealant - per tooth |
42 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
14 |
$928.20 |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$496.80 |