| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
12 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
14 |
$3K |
| D0330 |
Panoramic radiographic image |
19 |
19 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$704.90 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$393.00 |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
31 |
$304.73 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
15 |
$176.83 |
| D0270 |
|
19 |
19 |
$104.50 |