| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,156 |
4,956 |
$140K |
| D1120 |
Prophylaxis - child |
3,099 |
2,969 |
$123K |
| D1110 |
Prophylaxis - adult |
2,140 |
2,076 |
$91K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,650 |
1,584 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
598 |
478 |
$33K |
| D0330 |
Panoramic radiographic image |
1,162 |
1,118 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
300 |
288 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
178 |
141 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
215 |
204 |
$3K |
| D2332 |
|
23 |
13 |
$2K |
| D1351 |
Sealant - per tooth |
23 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
31 |
31 |
$819.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$781.85 |