| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
758 |
709 |
$16K |
| D1120 |
Prophylaxis - child |
449 |
415 |
$13K |
| D1110 |
Prophylaxis - adult |
276 |
259 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
371 |
356 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
54 |
52 |
$877.57 |
| D1999 |
|
125 |
86 |
$0.00 |