| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
265 |
265 |
$858.90 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
195 |
195 |
$569.80 |
| D0220 |
Intraoral - periapical first radiographic image |
205 |
191 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
21 |
15 |
$0.00 |
| D2950 |
|
19 |
13 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
46 |
45 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
95 |
89 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
68 |
68 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
168 |
72 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
64 |
64 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
40 |
35 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
13 |
$0.00 |