| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,003 |
224 |
$48K |
| D2933 |
|
340 |
85 |
$26K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
737 |
201 |
$24K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
314 |
76 |
$12K |
| D9420 |
|
474 |
343 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
180 |
66 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
232 |
154 |
$5K |
| D7111 |
|
269 |
69 |
$5K |
| D3230 |
|
115 |
24 |
$4K |
| D0240 |
|
380 |
222 |
$4K |
| D0274 |
Bitewings - four radiographic images |
363 |
242 |
$3K |
| D2140 |
|
123 |
28 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
272 |
172 |
$977.74 |
| D0350 |
|
479 |
206 |
$963.50 |
| D2330 |
|
25 |
13 |
$902.08 |
| D0220 |
Intraoral - periapical first radiographic image |
300 |
181 |
$504.00 |
| D0603 |
|
187 |
137 |
$140.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
313 |
73 |
$0.00 |