| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
238 |
238 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
256 |
256 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
77 |
42 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
13 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
68 |
68 |
$1K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$756.00 |