| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
127 |
43 |
$23K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
69 |
29 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
88 |
24 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
25 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
126 |
108 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
157 |
154 |
$3K |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$976.00 |