| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
86 |
64 |
$5K |
| D1120 |
Prophylaxis - child |
92 |
92 |
$4K |
| D1206 |
Topical application of fluoride varnish |
90 |
90 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
71 |
71 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
15 |
$728.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$704.16 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$458.88 |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$292.02 |