| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
85 |
85 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
192 |
192 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
559 |
558 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
98 |
98 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
620 |
574 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
348 |
188 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
124 |
81 |
$0.00 |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
17 |
15 |
$0.00 |
| D4341 |
|
400 |
164 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
730 |
714 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
565 |
565 |
$0.00 |
| D1110 |
Prophylaxis - adult |
321 |
321 |
$0.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
34 |
24 |
$0.00 |
| D0330 |
Panoramic radiographic image |
368 |
368 |
$0.00 |
| D2950 |
|
260 |
176 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
122 |
84 |
$0.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
213 |
116 |
$0.00 |