| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
225 |
225 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
116 |
116 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
17 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
89 |
89 |
$2K |
| D1206 |
Topical application of fluoride varnish |
95 |
95 |
$2K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$675.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$585.00 |