| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
95 |
26 |
$27.24 |
| D0999 |
Unspecified diagnostic procedure, by report |
1,092 |
416 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
169 |
57 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
12 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
74 |
12 |
$0.00 |
| D1110 |
Prophylaxis - adult |
50 |
25 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
96 |
36 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
152 |
54 |
$0.00 |
| D0330 |
Panoramic radiographic image |
24 |
12 |
$0.00 |