| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2335 |
|
187 |
135 |
$79K |
| D2332 |
|
143 |
120 |
$33K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
139 |
120 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
224 |
213 |
$15K |
| D1120 |
Prophylaxis - child |
210 |
210 |
$9K |
| D1206 |
Topical application of fluoride varnish |
212 |
212 |
$6K |
| D9110 |
|
104 |
101 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
161 |
161 |
$5K |
| D2394 |
|
27 |
24 |
$3K |
| D1351 |
Sealant - per tooth |
19 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
179 |
179 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
168 |
168 |
$779.52 |
| D0274 |
Bitewings - four radiographic images |
69 |
69 |
$757.72 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$704.16 |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$496.93 |