| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
1,653 |
1,456 |
$65K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
432 |
157 |
$42K |
| D0330 |
Panoramic radiographic image |
444 |
427 |
$37K |
| D1110 |
Prophylaxis - adult |
408 |
386 |
$23K |
| D0274 |
Bitewings - four radiographic images |
590 |
564 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
461 |
440 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
609 |
585 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
169 |
79 |
$18K |
| D5110 |
|
12 |
12 |
$10K |
| D1120 |
Prophylaxis - child |
227 |
211 |
$8K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
120 |
115 |
$8K |
| D1206 |
Topical application of fluoride varnish |
294 |
271 |
$8K |
| 90834 |
Psychotherapy, 45 minutes with patient |
59 |
39 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
146 |
141 |
$1K |
| D0272 |
Bitewings - two radiographic images |
40 |
40 |
$804.57 |
| 99394 |
Periodic comprehensive preventive medicine reevaluation, established patient, adolescent (12-17 years) |
12 |
12 |
$756.36 |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
14 |
$227.04 |
| H2019 |
Therapeutic behavioral services, per 15 minutes |
22 |
12 |
$63.84 |
| 90656 |
|
14 |
13 |
$29.77 |
| 99173 |
|
12 |
12 |
$26.40 |
| 1036F |
|
163 |
146 |
$0.00 |
| 3079F |
|
419 |
386 |
$0.00 |
| 3074F |
|
911 |
820 |
$0.00 |
| 3008F |
|
577 |
529 |
$0.00 |
| 3080F |
|
45 |
41 |
$0.00 |
| 3075F |
|
127 |
118 |
$0.00 |
| 3725F |
|
24 |
22 |
$0.00 |
| 3078F |
|
815 |
730 |
$0.00 |
| 3077F |
|
139 |
127 |
$0.00 |
| 4004F |
|
17 |
17 |
$0.00 |