| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
149 |
115 |
$0.00 |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$0.00 |
| D0330 |
Panoramic radiographic image |
64 |
30 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
107 |
80 |
$0.00 |
| D1120 |
Prophylaxis - child |
34 |
28 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
182 |
72 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
100 |
76 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
103 |
77 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
19 |
14 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$0.00 |