| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
289 |
274 |
$8K |
| D9999 |
Unspecified adjunctive procedure, by report |
15 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
40 |
39 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
56 |
54 |
$655.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
565 |
477 |
$614.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
38 |
38 |
$582.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
152 |
116 |
$490.65 |
| D0220 |
Intraoral - periapical first radiographic image |
132 |
127 |
$454.00 |
| D1999 |
|
463 |
382 |
$380.00 |
| D0350 |
|
50 |
12 |
$0.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$0.00 |