| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
172 |
172 |
$4K |
| D1110 |
Prophylaxis - adult |
88 |
88 |
$4K |
| D1120 |
Prophylaxis - child |
85 |
85 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
134 |
134 |
$3K |
| D0251 |
|
167 |
166 |
$2K |
| D1206 |
Topical application of fluoride varnish |
66 |
66 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$880.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$520.00 |
| D9920 |
|
12 |
12 |
$300.00 |