| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
543 |
539 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
430 |
252 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
84 |
56 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
559 |
555 |
$3K |
| D1110 |
Prophylaxis - adult |
83 |
83 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$639.28 |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
42 |
$44.02 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
13 |
$0.00 |