| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,262 |
1,246 |
$109K |
| D1120 |
Prophylaxis - child |
2,051 |
2,011 |
$108K |
| D0120 |
Periodic oral evaluation - established patient |
1,782 |
1,732 |
$97K |
| H1000 |
Prenatal care, at-risk assessment |
625 |
397 |
$65K |
| D0220 |
Intraoral - periapical first radiographic image |
2,160 |
2,102 |
$64K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
404 |
361 |
$33K |
| D1351 |
Sealant - per tooth |
2,714 |
741 |
$24K |
| D0191 |
|
458 |
456 |
$10K |
| D1206 |
Topical application of fluoride varnish |
3,426 |
3,368 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
68 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
25 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
132 |
132 |
$4K |
| D1330 |
|
3,659 |
3,601 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
16 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,146 |
1,958 |
$2K |
| D7111 |
|
21 |
17 |
$2K |
| 99403 |
|
13 |
13 |
$1K |
| D1354 |
|
1,510 |
412 |
$1K |
| D1999 |
|
18 |
18 |
$1K |
| D0274 |
Bitewings - four radiographic images |
909 |
898 |
$964.00 |
| D9996 |
|
1,212 |
1,172 |
$697.76 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
233 |
226 |
$633.00 |
| D0272 |
Bitewings - two radiographic images |
769 |
739 |
$573.38 |
| D9999 |
Unspecified adjunctive procedure, by report |
37 |
37 |
$475.00 |
| 90686 |
|
93 |
92 |
$404.00 |
| D0140 |
Limited oral evaluation - problem focused |
58 |
57 |
$369.48 |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
38 |
38 |
$286.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
13 |
13 |
$260.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
174 |
174 |
$59.04 |
| D0350 |
|
208 |
207 |
$41.58 |
| 90651 |
|
13 |
13 |
$0.00 |
| D0602 |
|
88 |
88 |
$0.00 |
| D0601 |
|
58 |
58 |
$0.00 |
| D0603 |
|
51 |
51 |
$0.00 |
| D9986 |
|
630 |
605 |
$0.00 |
| D0330 |
Panoramic radiographic image |
92 |
92 |
$0.00 |
| 90715 |
|
30 |
30 |
$0.00 |