| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
1,620 |
1,490 |
$243K |
| D1351 |
Sealant - per tooth |
2,912 |
785 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
1,088 |
1,078 |
$57K |
| D1110 |
Prophylaxis - adult |
707 |
694 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
678 |
662 |
$44K |
| D1206 |
Topical application of fluoride varnish |
3,078 |
3,032 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
267 |
196 |
$24K |
| D1120 |
Prophylaxis - child |
1,156 |
1,139 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
587 |
577 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
116 |
102 |
$7K |
| D0191 |
|
1,177 |
1,162 |
$6K |
| D1330 |
|
3,173 |
3,128 |
$4K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$4K |
| D0272 |
Bitewings - two radiographic images |
725 |
714 |
$3K |
| D0274 |
Bitewings - four radiographic images |
526 |
516 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
48 |
37 |
$2K |
| 99395 |
Periodic comprehensive preventive medicine reevaluation, established patient, 18-39 years |
13 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
342 |
116 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
56 |
56 |
$1K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
227 |
217 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
534 |
518 |
$1K |
| 90672 |
|
256 |
250 |
$1K |
| 90473 |
|
311 |
304 |
$887.50 |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
137 |
131 |
$623.40 |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
56 |
55 |
$360.50 |
| 90686 |
|
29 |
29 |
$121.00 |
| 90715 |
|
53 |
51 |
$37.50 |
| D9986 |
|
742 |
718 |
$0.00 |
| D9987 |
|
13 |
12 |
$0.00 |
| 90651 |
|
14 |
13 |
$0.00 |