| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
581 |
207 |
$288K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
136 |
90 |
$39K |
| D7140 |
Extraction, erupted tooth or exposed root |
94 |
59 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
171 |
171 |
$5K |
| D1120 |
Prophylaxis - child |
151 |
151 |
$4K |
| D1206 |
Topical application of fluoride varnish |
122 |
122 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
19 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$305.34 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
13 |
$294.70 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$120.40 |