| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
108 |
108 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
115 |
66 |
$0.00 |
| D7880 |
|
14 |
14 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
22 |
13 |
$0.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
44 |
14 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
47 |
46 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
150 |
141 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
155 |
155 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
205 |
205 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
44 |
44 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
140 |
80 |
$0.00 |