| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
867 |
867 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,171 |
1,171 |
$32K |
| D1206 |
Topical application of fluoride varnish |
399 |
399 |
$11K |
| D1110 |
Prophylaxis - adult |
81 |
81 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
304 |
304 |
$4K |
| D0272 |
Bitewings - two radiographic images |
144 |
144 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$931.79 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$386.65 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$332.50 |
| D1999 |
|
166 |
162 |
$0.00 |