| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
384 |
363 |
$0.00 |
| D0330 |
Panoramic radiographic image |
373 |
373 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
93 |
60 |
$0.00 |
| D1110 |
Prophylaxis - adult |
64 |
64 |
$0.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
246 |
77 |
$0.00 |
| D2950 |
|
142 |
118 |
$0.00 |
| D4341 |
|
416 |
168 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
74 |
38 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
142 |
142 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
406 |
405 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
328 |
149 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
217 |
217 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
293 |
293 |
$0.00 |
| D7230 |
|
20 |
14 |
$0.00 |
| D3120 |
|
61 |
40 |
$0.00 |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
67 |
63 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
68 |
46 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
33 |
33 |
$0.00 |