| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
826 |
826 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
815 |
815 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
233 |
178 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
756 |
756 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
116 |
91 |
$3K |
| D0273 |
|
437 |
437 |
$2K |
| D1206 |
Topical application of fluoride varnish |
103 |
103 |
$2K |
| D0272 |
Bitewings - two radiographic images |
129 |
129 |
$1K |
| D0603 |
|
126 |
126 |
$1K |
| D1351 |
Sealant - per tooth |
555 |
106 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
13 |
$719.50 |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$696.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$161.00 |
| D1320 |
|
12 |
12 |
$72.00 |