| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
210 |
96 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
102 |
59 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
118 |
118 |
$3K |
| D1110 |
Prophylaxis - adult |
97 |
97 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
140 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
120 |
56 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
31 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
38 |
$571.60 |
| D0120 |
Periodic oral evaluation - established patient |
25 |
25 |
$358.25 |