| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,462 |
213 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
297 |
120 |
$26K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
942 |
561 |
$21K |
| D1206 |
Topical application of fluoride varnish |
989 |
657 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
812 |
570 |
$18K |
| D1120 |
Prophylaxis - child |
627 |
418 |
$17K |
| D1110 |
Prophylaxis - adult |
318 |
216 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
207 |
41 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
62 |
29 |
$5K |
| D0274 |
Bitewings - four radiographic images |
144 |
114 |
$5K |
| D1353 |
|
95 |
26 |
$4K |
| D2140 |
|
96 |
29 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
242 |
186 |
$4K |
| D0272 |
Bitewings - two radiographic images |
131 |
76 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
52 |
$2K |
| D2160 |
|
17 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
33 |
29 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
121 |
75 |
$2K |