| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
18 |
$817.97 |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$627.42 |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$420.48 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$161.83 |
| D0120 |
Periodic oral evaluation - established patient |
21 |
21 |
$157.16 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
13 |
$85.72 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
24 |
$15.05 |
| D0220 |
Intraoral - periapical first radiographic image |
33 |
29 |
$8.04 |