| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
43 |
30 |
$4K |
| D1120 |
Prophylaxis - child |
47 |
47 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
56 |
56 |
$2K |
| D1206 |
Topical application of fluoride varnish |
43 |
43 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$307.59 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$259.22 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$248.56 |