| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
797 |
452 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
479 |
294 |
$17K |
| D1120 |
Prophylaxis - child |
513 |
513 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
532 |
532 |
$11K |
| D1351 |
Sealant - per tooth |
598 |
117 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
521 |
521 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
117 |
67 |
$3K |
| D0273 |
|
202 |
202 |
$891.58 |
| D1206 |
Topical application of fluoride varnish |
50 |
50 |
$431.50 |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$414.00 |
| D0603 |
|
31 |
31 |
$310.00 |
| D0602 |
|
22 |
22 |
$220.00 |