| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
61 |
61 |
$156.00 |
| D0330 |
Panoramic radiographic image |
34 |
34 |
$156.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$152.00 |
| D0274 |
Bitewings - four radiographic images |
32 |
32 |
$145.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$105.00 |
| D0603 |
|
35 |
35 |
$55.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
33 |
33 |
$45.00 |
| D1310 |
|
35 |
35 |
$0.00 |
| D1330 |
|
43 |
43 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
17 |
$0.00 |