| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
227 |
227 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
249 |
249 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
45 |
$4K |
| D0272 |
Bitewings - two radiographic images |
121 |
121 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
129 |
129 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
62 |
62 |
$930.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$819.36 |