| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
395 |
230 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
165 |
106 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
90 |
67 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
187 |
177 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
148 |
135 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
89 |
87 |
$3K |
| D2950 |
|
12 |
12 |
$1K |
| D0160 |
|
17 |
17 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$300.50 |