| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
472 |
458 |
$119K |
| D7140 |
Extraction, erupted tooth or exposed root |
957 |
334 |
$111K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
687 |
325 |
$74K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
818 |
338 |
$52K |
| D2394 |
|
250 |
125 |
$16K |
| D2330 |
|
18 |
12 |
$857.24 |
| D1206 |
Topical application of fluoride varnish |
470 |
456 |
$90.27 |
| D1120 |
Prophylaxis - child |
475 |
460 |
$45.14 |
| D1351 |
Sealant - per tooth |
133 |
60 |
$0.00 |