| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
100 |
100 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
128 |
128 |
$0.00 |
| D2950 |
|
68 |
46 |
$0.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
121 |
114 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
49 |
36 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
50 |
49 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
80 |
80 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
26 |
26 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
104 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
82 |
82 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
127 |
63 |
$0.00 |