| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
819 |
819 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
156 |
89 |
$13K |
| D1110 |
Prophylaxis - adult |
110 |
110 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
42 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
148 |
148 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
20 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
67 |
67 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$290.50 |
| D1999 |
|
24 |
23 |
$0.00 |