| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2954 |
|
80 |
60 |
$11K |
| D0330 |
Panoramic radiographic image |
156 |
156 |
$7K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
16 |
14 |
$6K |
| D1110 |
Prophylaxis - adult |
169 |
169 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
215 |
215 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
78 |
44 |
$5K |
| D2394 |
|
60 |
43 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
91 |
91 |
$2K |
| D0274 |
Bitewings - four radiographic images |
47 |
47 |
$920.00 |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
31 |
$902.36 |
| D0220 |
Intraoral - periapical first radiographic image |
179 |
177 |
$895.00 |
| D0272 |
Bitewings - two radiographic images |
70 |
70 |
$670.00 |