| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
13 |
$2K |
| D1110 |
Prophylaxis - adult |
48 |
44 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
47 |
$1K |
| D0274 |
Bitewings - four radiographic images |
48 |
44 |
$1K |
| D0330 |
Panoramic radiographic image |
23 |
21 |
$654.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$566.54 |
| D0220 |
Intraoral - periapical first radiographic image |
63 |
59 |
$444.00 |
| D1310 |
|
66 |
64 |
$386.31 |
| D1330 |
|
65 |
63 |
$384.04 |
| D0230 |
Intraoral - periapical each additional radiographic image |
54 |
50 |
$368.00 |