| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 41899 |
Unlisted procedure, dentoalveolar structures |
783 |
750 |
$469K |
| T1015 |
Clinic visit/encounter, all-inclusive |
424 |
419 |
$265K |
| D2934 |
|
167 |
59 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,261 |
331 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
21 |
16 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
70 |
37 |
$0.00 |
| D1120 |
Prophylaxis - child |
24 |
24 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
56 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
86 |
55 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
217 |
86 |
$0.00 |
| D9420 |
|
97 |
97 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
15 |
$0.00 |