| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,957 |
469 |
$349K |
| D7140 |
Extraction, erupted tooth or exposed root |
845 |
240 |
$107K |
| D9420 |
|
598 |
598 |
$51K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
340 |
131 |
$30K |
| D1120 |
Prophylaxis - child |
565 |
565 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
736 |
736 |
$19K |
| D0272 |
Bitewings - two radiographic images |
502 |
502 |
$10K |
| D1206 |
Topical application of fluoride varnish |
355 |
355 |
$10K |
| 99202 |
Office or other outpatient visit for the evaluation and management of a new patient, straightforward |
127 |
127 |
$9K |
| 99204 |
Office or other outpatient visit for the evaluation and management of a new patient, moderate complexity |
51 |
51 |
$7K |
| 99203 |
Office or other outpatient visit for the evaluation and management of a new patient, low complexity |
67 |
67 |
$6K |
| D9310 |
|
64 |
64 |
$4K |
| D1351 |
Sealant - per tooth |
71 |
24 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
126 |
126 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
57 |
57 |
$730.30 |
| D1208 |
Topical application of fluoride, excluding varnish |
51 |
51 |
$645.00 |
| D0240 |
|
20 |
14 |
$272.00 |
| D9995 |
|
12 |
12 |
$0.00 |