| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
647 |
642 |
$414.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
453 |
340 |
$133.00 |
| D0220 |
Intraoral - periapical first radiographic image |
653 |
632 |
$110.00 |
| D1110 |
Prophylaxis - adult |
656 |
651 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
265 |
264 |
$0.00 |
| D0330 |
Panoramic radiographic image |
462 |
458 |
$0.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
106 |
70 |
$0.00 |
| D1120 |
Prophylaxis - child |
97 |
96 |
$0.00 |
| D1999 |
|
649 |
582 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
896 |
889 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
229 |
224 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
99 |
98 |
$0.00 |