| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
437 |
141 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
124 |
28 |
$474.70 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
121 |
39 |
$264.85 |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
12 |
$90.00 |
| D0330 |
Panoramic radiographic image |
45 |
12 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
108 |
33 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
46 |
16 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
52 |
15 |
$0.00 |