| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
81 |
81 |
$105.00 |
| D0220 |
Intraoral - periapical first radiographic image |
57 |
57 |
$39.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
101 |
101 |
$38.00 |
| D0274 |
Bitewings - four radiographic images |
74 |
74 |
$0.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$0.00 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
122 |
122 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
57 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$0.00 |