| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$112.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$38.00 |
| D0603 |
|
18 |
18 |
$11.00 |
| D1330 |
|
58 |
58 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
21 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
16 |
16 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
37 |
20 |
$0.00 |
| D1310 |
|
43 |
43 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
27 |
$0.00 |