| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
928 |
908 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
1,363 |
1,340 |
$20K |
| D1120 |
Prophylaxis - child |
240 |
239 |
$6K |
| D9410 |
|
153 |
88 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
112 |
111 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
73 |
72 |
$2K |
| D0274 |
Bitewings - four radiographic images |
98 |
96 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
90 |
90 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
24 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
13 |
$954.74 |
| D1999 |
|
200 |
193 |
$0.00 |