| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,242 |
5,242 |
$218K |
| D0120 |
Periodic oral evaluation - established patient |
7,097 |
7,097 |
$187K |
| D1110 |
Prophylaxis - adult |
2,330 |
2,330 |
$117K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,306 |
940 |
$92K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,036 |
5,036 |
$69K |
| D1206 |
Topical application of fluoride varnish |
2,010 |
2,009 |
$58K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
904 |
723 |
$46K |
| D1351 |
Sealant - per tooth |
160 |
66 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
135 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
24 |
24 |
$700.50 |
| D7111 |
|
20 |
16 |
$700.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$177.90 |