| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
461 |
461 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
152 |
82 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
95 |
95 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
216 |
214 |
$2K |
| D0274 |
Bitewings - four radiographic images |
83 |
83 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
67 |
$2K |
| D4346 |
|
13 |
13 |
$928.22 |
| D9110 |
|
16 |
16 |
$901.45 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$445.41 |