| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,887 |
796 |
$329K |
| D9420 |
|
952 |
947 |
$302K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
4,397 |
878 |
$238K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
995 |
386 |
$57K |
| D2933 |
|
152 |
44 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
180 |
89 |
$14K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
244 |
84 |
$13K |
| D0272 |
Bitewings - two radiographic images |
577 |
574 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
109 |
68 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
753 |
750 |
$4K |
| D1351 |
Sealant - per tooth |
169 |
57 |
$4K |
| D2330 |
|
74 |
39 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
482 |
425 |
$2K |
| D0274 |
Bitewings - four radiographic images |
137 |
137 |
$2K |
| D2140 |
|
33 |
13 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
949 |
944 |
$943.00 |