| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
59 |
12 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
13 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
35 |
35 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$939.25 |
| D1120 |
Prophylaxis - child |
19 |
19 |
$932.58 |
| D0220 |
Intraoral - periapical first radiographic image |
52 |
47 |
$832.52 |
| D0230 |
Intraoral - periapical each additional radiographic image |
65 |
23 |
$716.28 |
| D1206 |
Topical application of fluoride varnish |
19 |
19 |
$614.16 |
| D0330 |
Panoramic radiographic image |
13 |
12 |
$580.31 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$274.00 |