| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
25 |
$3K |
| D1206 |
Topical application of fluoride varnish |
80 |
80 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
42 |
37 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$1K |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$626.50 |
| D0330 |
Panoramic radiographic image |
18 |
18 |
$539.46 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$421.80 |
| D0120 |
Periodic oral evaluation - established patient |
15 |
15 |
$366.00 |
| D0274 |
Bitewings - four radiographic images |
18 |
17 |
$317.24 |