| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
827 |
827 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,302 |
1,301 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
439 |
303 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
623 |
333 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
551 |
551 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
36 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
35 |
30 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
30 |
$424.48 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$219.45 |