| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
192 |
190 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
147 |
142 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
137 |
133 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
27 |
12 |
$0.00 |
| D0330 |
Panoramic radiographic image |
51 |
51 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
272 |
134 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
38 |
38 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
103 |
102 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
71 |
70 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
15 |
$0.00 |
| D9630 |
|
35 |
31 |
$0.00 |