| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
3,988 |
3,954 |
$74K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,280 |
1,256 |
$65K |
| D1351 |
Sealant - per tooth |
4,469 |
1,420 |
$63K |
| D1120 |
Prophylaxis - child |
1,813 |
1,794 |
$55K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
421 |
326 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
893 |
888 |
$44K |
| 99403 |
|
206 |
198 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
347 |
253 |
$24K |
| D0191 |
|
1,660 |
1,650 |
$23K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
161 |
137 |
$19K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
129 |
121 |
$19K |
| D1110 |
Prophylaxis - adult |
210 |
209 |
$18K |
| D1330 |
|
3,971 |
3,936 |
$10K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
66 |
54 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
939 |
914 |
$8K |
| D9999 |
Unspecified adjunctive procedure, by report |
245 |
245 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
63 |
62 |
$5K |
| D0272 |
Bitewings - two radiographic images |
858 |
844 |
$3K |
| H0049 |
Alcohol and/or drug screening |
346 |
307 |
$3K |
| D0240 |
|
147 |
91 |
$3K |
| 99203 |
Office or other outpatient visit for the evaluation and management of a new patient, low complexity |
17 |
14 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
100 |
77 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
826 |
588 |
$1K |
| D0274 |
Bitewings - four radiographic images |
81 |
81 |
$1K |
| D1354 |
|
124 |
27 |
$1K |
| D1999 |
|
16 |
16 |
$820.00 |
| D0190 |
|
243 |
243 |
$615.26 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
128 |
116 |
$560.00 |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
15 |
13 |
$283.54 |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
43 |
37 |
$147.00 |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
12 |
12 |
$88.00 |