| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,591 |
1,412 |
$199K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,187 |
1,081 |
$179K |
| D0120 |
Periodic oral evaluation - established patient |
4,298 |
4,295 |
$123K |
| D1110 |
Prophylaxis - adult |
1,719 |
1,719 |
$97K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
419 |
287 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,100 |
1,099 |
$31K |
| D1120 |
Prophylaxis - child |
510 |
510 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
802 |
802 |
$11K |
| D2330 |
|
123 |
70 |
$7K |
| D1351 |
Sealant - per tooth |
129 |
47 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
358 |
358 |
$5K |
| D1206 |
Topical application of fluoride varnish |
102 |
102 |
$3K |
| D2332 |
|
18 |
13 |
$2K |