| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
53 |
53 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
94 |
86 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
30 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
13 |
$614.14 |
| D1120 |
Prophylaxis - child |
72 |
71 |
$88.47 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$54.56 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$52.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
178 |
69 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$0.00 |