| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
176 |
91 |
$87K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
405 |
190 |
$68K |
| D1110 |
Prophylaxis - adult |
202 |
197 |
$13K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
13 |
12 |
$10K |
| D2954 |
|
107 |
53 |
$8K |
| D2332 |
|
31 |
12 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
12 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
70 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
261 |
213 |
$3K |
| D0330 |
Panoramic radiographic image |
69 |
63 |
$3K |
| D0274 |
Bitewings - four radiographic images |
42 |
42 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$567.12 |