| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
154 |
30 |
$18K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
31 |
12 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
12 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
43 |
43 |
$2K |
| D1206 |
Topical application of fluoride varnish |
43 |
43 |
$922.50 |
| D0120 |
Periodic oral evaluation - established patient |
27 |
27 |
$660.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$594.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$435.00 |