| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
72 |
72 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
42 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
129 |
128 |
$385.15 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$376.88 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$62.00 |
| D1110 |
Prophylaxis - adult |
74 |
74 |
$49.00 |
| D1330 |
|
71 |
71 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
79 |
79 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
108 |
95 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
60 |
60 |
$0.00 |
| D0350 |
|
15 |
15 |
$0.00 |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$0.00 |