| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
442 |
57 |
$20K |
| D2332 |
|
48 |
12 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
17 |
$706.00 |
| D1110 |
Prophylaxis - adult |
52 |
52 |
$271.00 |
| D0330 |
Panoramic radiographic image |
35 |
35 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
14 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
47 |
47 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
49 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
49 |
49 |
$0.00 |
| D1330 |
|
34 |
34 |
$0.00 |
| D2331 |
|
57 |
15 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
33 |
33 |
$0.00 |