| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
490 |
489 |
$39K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
264 |
231 |
$14K |
| D0272 |
Bitewings - two radiographic images |
315 |
314 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
106 |
106 |
$10K |
| D1351 |
Sealant - per tooth |
393 |
127 |
$7K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
797 |
774 |
$6K |
| D0274 |
Bitewings - four radiographic images |
159 |
159 |
$5K |
| D1206 |
Topical application of fluoride varnish |
760 |
759 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
47 |
47 |
$4K |
| D1999 |
|
56 |
56 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
34 |
$3K |
| D1120 |
Prophylaxis - child |
511 |
510 |
$2K |
| D0330 |
Panoramic radiographic image |
103 |
103 |
$2K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
336 |
322 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
16 |
$2K |
| D1330 |
|
700 |
699 |
$1K |
| D9999 |
Unspecified adjunctive procedure, by report |
78 |
78 |
$480.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$436.29 |
| D0191 |
|
29 |
29 |
$398.32 |
| D0220 |
Intraoral - periapical first radiographic image |
21 |
21 |
$359.69 |
| D1110 |
Prophylaxis - adult |
166 |
166 |
$80.30 |
| 90734 |
|
32 |
30 |
$22.00 |
| 90651 |
|
69 |
64 |
$11.00 |
| 90686 |
|
28 |
28 |
$0.00 |
| 90715 |
|
85 |
83 |
$0.00 |
| 90633 |
|
23 |
18 |
$0.00 |
| 90710 |
|
14 |
14 |
$0.00 |