| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
15 |
15 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
110 |
80 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
322 |
170 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
550 |
550 |
$0.00 |
| D1110 |
Prophylaxis - adult |
676 |
676 |
$0.00 |
| D2950 |
|
86 |
72 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
93 |
91 |
$0.00 |
| D1120 |
Prophylaxis - child |
135 |
135 |
$0.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
212 |
58 |
$0.00 |
| D4341 |
|
254 |
97 |
$0.00 |
| D2332 |
|
16 |
12 |
$0.00 |
| D4910 |
|
12 |
12 |
$0.00 |
| D9630 |
|
342 |
342 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
541 |
277 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
386 |
386 |
$0.00 |
| D9994 |
|
1,025 |
1,025 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
712 |
712 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
244 |
244 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
228 |
142 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
351 |
351 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
109 |
106 |
$0.00 |