| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
165 |
162 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
25 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
50 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
172 |
169 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
26 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
172 |
169 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
13 |
$0.00 |