| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
471 |
84 |
$3K |
| D1120 |
Prophylaxis - child |
870 |
322 |
$536.74 |
| D0120 |
Periodic oral evaluation - established patient |
197 |
86 |
$511.88 |
| D1208 |
Topical application of fluoride, excluding varnish |
823 |
305 |
$317.18 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
529 |
182 |
$0.00 |
| D2331 |
|
1,153 |
94 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
26 |
13 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
481 |
82 |
$0.00 |
| D2335 |
|
461 |
64 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
130 |
43 |
$0.00 |