| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
286 |
213 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
632 |
585 |
$19K |
| D2740 |
Crown - porcelain/ceramic |
14 |
12 |
$8K |
| D0330 |
Panoramic radiographic image |
47 |
47 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
69 |
69 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
34 |
34 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$873.48 |
| D0220 |
Intraoral - periapical first radiographic image |
52 |
51 |
$640.75 |
| D0274 |
Bitewings - four radiographic images |
19 |
19 |
$542.64 |