| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
801 |
801 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,090 |
1,090 |
$28K |
| D1110 |
Prophylaxis - adult |
217 |
217 |
$11K |
| D1206 |
Topical application of fluoride varnish |
186 |
186 |
$5K |
| D0272 |
Bitewings - two radiographic images |
205 |
205 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
216 |
216 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$854.05 |