| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
390 |
223 |
$31K |
| D1110 |
Prophylaxis - adult |
479 |
477 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
197 |
127 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
547 |
547 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
260 |
152 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
290 |
290 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
93 |
41 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$213.50 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$152.60 |