| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
244 |
166 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
515 |
467 |
$17K |
| D1120 |
Prophylaxis - child |
555 |
526 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
118 |
115 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
205 |
178 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
15 |
$3K |
| D1206 |
Topical application of fluoride varnish |
95 |
94 |
$2K |
| D0272 |
Bitewings - two radiographic images |
86 |
84 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
43 |
$577.36 |
| D1999 |
|
117 |
99 |
$0.00 |