| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,117 |
1,105 |
$360K |
| D7140 |
Extraction, erupted tooth or exposed root |
433 |
428 |
$79K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
265 |
264 |
$49K |
| D0272 |
Bitewings - two radiographic images |
266 |
265 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
165 |
164 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
15 |
$1K |
| D1351 |
Sealant - per tooth |
12 |
12 |
$678.80 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
18 |
18 |
$509.10 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
16 |
$509.10 |