| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
160 |
160 |
$68K |
| D0140 |
Limited oral evaluation - problem focused |
335 |
332 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
455 |
414 |
$5K |
| D1110 |
Prophylaxis - adult |
67 |
67 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
26 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
52 |
52 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$575.76 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$288.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$274.24 |