| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
7,176 |
1,613 |
$959K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,939 |
696 |
$158K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,504 |
411 |
$103K |
| D2390 |
|
359 |
103 |
$76K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
542 |
237 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
534 |
217 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,308 |
1,294 |
$13K |
| D1351 |
Sealant - per tooth |
357 |
121 |
$7K |
| D1999 |
|
407 |
405 |
$5K |
| D2330 |
|
77 |
38 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
205 |
204 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
164 |
85 |
$376.83 |