| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2950 |
|
184 |
96 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
57 |
$488.40 |
| D0220 |
Intraoral - periapical first radiographic image |
194 |
164 |
$305.13 |
| D0120 |
Periodic oral evaluation - established patient |
31 |
31 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
31 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
146 |
63 |
$0.00 |
| D4211 |
|
50 |
41 |
$0.00 |
| D3120 |
|
136 |
55 |
$0.00 |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
16 |
14 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
169 |
81 |
$0.00 |
| D2394 |
|
93 |
39 |
$0.00 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$0.00 |