| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
177 |
177 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
156 |
156 |
$407.00 |
| D0220 |
Intraoral - periapical first radiographic image |
254 |
226 |
$159.83 |
| D2740 |
Crown - porcelain/ceramic |
95 |
55 |
$0.00 |
| D2950 |
|
105 |
59 |
$0.00 |
| D1110 |
Prophylaxis - adult |
118 |
117 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
15 |
$0.00 |
| D0270 |
|
18 |
15 |
$0.00 |
| D4910 |
|
12 |
12 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
54 |
40 |
$0.00 |
| D4211 |
|
53 |
40 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
123 |
58 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
70 |
69 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
64 |
29 |
$0.00 |