| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
14 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
35 |
35 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
21 |
19 |
$352.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
17 |
$152.25 |