| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
92 |
90 |
$70.00 |
| D0220 |
Intraoral - periapical first radiographic image |
208 |
203 |
$26.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
155 |
149 |
$9.00 |
| D1120 |
Prophylaxis - child |
19 |
19 |
$0.00 |
| D4910 |
|
19 |
19 |
$0.00 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$0.00 |
| D1110 |
Prophylaxis - adult |
113 |
113 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
137 |
137 |
$0.00 |
| D4921 |
|
86 |
52 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
201 |
201 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
179 |
179 |
$0.00 |
| D0603 |
|
90 |
90 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
26 |
26 |
$0.00 |