| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
128 |
124 |
$3K |
| D1110 |
Prophylaxis - adult |
133 |
126 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
94 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
25 |
21 |
$672.60 |
| D9920 |
|
30 |
29 |
$669.20 |
| D0120 |
Periodic oral evaluation - established patient |
52 |
37 |
$343.39 |
| D0140 |
Limited oral evaluation - problem focused |
19 |
18 |
$251.00 |
| D0220 |
Intraoral - periapical first radiographic image |
21 |
20 |
$52.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
149 |
142 |
$37.95 |
| D0350 |
|
73 |
56 |
$5.00 |
| D1330 |
|
147 |
140 |
$0.00 |