| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
68 |
68 |
$45K |
| D2750 |
|
15 |
13 |
$11K |
| D1110 |
Prophylaxis - adult |
205 |
205 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
192 |
189 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
473 |
434 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
28 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
28 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
83 |
83 |
$2K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$1K |
| D0274 |
Bitewings - four radiographic images |
61 |
61 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
60 |
40 |
$550.58 |