| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,687 |
503 |
$167K |
| D9420 |
|
843 |
793 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,651 |
514 |
$8K |
| D0240 |
|
176 |
167 |
$7K |
| D0272 |
Bitewings - two radiographic images |
230 |
219 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
399 |
214 |
$692.94 |
| D2332 |
|
153 |
63 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
37 |
37 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
41 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,188 |
430 |
$0.00 |
| D7111 |
|
827 |
319 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
12 |
$0.00 |