| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
246 |
156 |
$35K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
174 |
108 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
461 |
461 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
100 |
64 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
156 |
152 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
13 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
164 |
160 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
16 |
16 |
$412.44 |