| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,644 |
333 |
$46K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
809 |
804 |
$37K |
| D1120 |
Prophylaxis - child |
989 |
989 |
$31K |
| D1206 |
Topical application of fluoride varnish |
1,386 |
1,384 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,163 |
1,162 |
$26K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
342 |
247 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
197 |
157 |
$13K |
| D1110 |
Prophylaxis - adult |
334 |
333 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
176 |
126 |
$12K |
| D0272 |
Bitewings - two radiographic images |
659 |
659 |
$12K |
| D0274 |
Bitewings - four radiographic images |
368 |
367 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
143 |
122 |
$8K |
| D1330 |
|
1,221 |
1,220 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
546 |
544 |
$5K |
| D0603 |
|
449 |
448 |
$5K |
| D0602 |
|
448 |
448 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
372 |
371 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
82 |
82 |
$2K |
| D1310 |
|
160 |
160 |
$2K |
| D0330 |
Panoramic radiographic image |
30 |
30 |
$1K |
| D0601 |
|
96 |
96 |
$988.80 |
| D2140 |
|
20 |
19 |
$958.56 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$843.72 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
34 |
34 |
$767.12 |
| D1320 |
|
23 |
23 |
$230.00 |