| Code | Description | Claims | Beneficiaries | Total Paid |
| D1351 |
Sealant - per tooth |
85,979 |
26,373 |
$1.56M |
| D1206 |
Topical application of fluoride varnish |
67,159 |
66,380 |
$806K |
| D0191 |
|
63,029 |
62,817 |
$752K |
| D0120 |
Periodic oral evaluation - established patient |
9,374 |
8,835 |
$581K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
4,376 |
3,821 |
$494K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,620 |
2,007 |
$173K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,933 |
2,240 |
$137K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,124 |
2,005 |
$108K |
| D1110 |
Prophylaxis - adult |
1,820 |
1,735 |
$105K |
| D1330 |
|
68,155 |
67,392 |
$88K |
| 99403 |
|
568 |
514 |
$72K |
| D0330 |
Panoramic radiographic image |
1,117 |
1,025 |
$68K |
| D1120 |
Prophylaxis - child |
7,680 |
7,237 |
$60K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
185 |
170 |
$22K |
| 99385 |
|
191 |
164 |
$21K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
2,604 |
2,320 |
$17K |
| D9920 |
|
360 |
345 |
$17K |
| D0145 |
Oral evaluation for a patient under three years of age |
353 |
343 |
$17K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
4,005 |
3,591 |
$17K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
130 |
126 |
$17K |
| D9999 |
Unspecified adjunctive procedure, by report |
706 |
706 |
$16K |
| D0274 |
Bitewings - four radiographic images |
6,644 |
6,259 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
11,128 |
10,377 |
$13K |
| 99395 |
Periodic comprehensive preventive medicine reevaluation, established patient, 18-39 years |
115 |
103 |
$11K |
| 99202 |
Office or other outpatient visit for the evaluation and management of a new patient, straightforward |
56 |
51 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,612 |
9,601 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
66 |
66 |
$6K |
| D0272 |
Bitewings - two radiographic images |
2,457 |
2,267 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
27 |
$3K |
| 99203 |
Office or other outpatient visit for the evaluation and management of a new patient, low complexity |
16 |
15 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
99 |
99 |
$943.36 |
| 90633 |
|
785 |
698 |
$928.51 |
| D0140 |
Limited oral evaluation - problem focused |
53 |
53 |
$772.08 |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$672.10 |
| 90716 |
|
578 |
537 |
$665.50 |
| 90715 |
|
330 |
282 |
$412.52 |
| 90670 |
|
253 |
227 |
$368.50 |
| 90698 |
|
28 |
27 |
$368.50 |
| 90700 |
|
46 |
39 |
$297.00 |
| 90734 |
|
100 |
76 |
$280.50 |
| 90744 |
|
359 |
335 |
$231.02 |
| 90696 |
|
41 |
27 |
$209.00 |
| 90651 |
|
250 |
208 |
$207.90 |
| D9986 |
|
6,579 |
5,895 |
$185.28 |
| 90707 |
|
369 |
335 |
$170.50 |
| 90686 |
|
102 |
87 |
$159.50 |
| 90713 |
|
257 |
207 |
$44.00 |
| 90710 |
|
42 |
40 |
$0.00 |
| 90658 |
|
12 |
12 |
$0.00 |
| D1310 |
|
54 |
54 |
$0.00 |
| 90619 |
|
15 |
15 |
$0.00 |