| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
3,015 |
2,820 |
$167K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
685 |
626 |
$162K |
| D1120 |
Prophylaxis - child |
1,106 |
992 |
$114K |
| D1110 |
Prophylaxis - adult |
504 |
476 |
$55K |
| D0140 |
Limited oral evaluation - problem focused |
525 |
494 |
$49K |
| D0330 |
Panoramic radiographic image |
345 |
316 |
$44K |
| D7140 |
Extraction, erupted tooth or exposed root |
520 |
261 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
268 |
191 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
263 |
166 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
487 |
419 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
478 |
434 |
$11K |
| D0274 |
Bitewings - four radiographic images |
366 |
345 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
52 |
40 |
$5K |
| 99394 |
Periodic comprehensive preventive medicine reevaluation, established patient, adolescent (12-17 years) |
21 |
21 |
$5K |
| D1351 |
Sealant - per tooth |
2,038 |
364 |
$5K |
| 99393 |
Periodic comprehensive preventive medicine reevaluation, established patient, late childhood (5-11 years) |
15 |
15 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
893 |
772 |
$2K |
| D0272 |
Bitewings - two radiographic images |
201 |
163 |
$2K |
| D1354 |
|
776 |
201 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
15 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
974 |
378 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
35 |
15 |
$278.55 |
| 99173 |
|
26 |
26 |
$241.76 |
| D0270 |
|
150 |
134 |
$231.78 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$194.60 |
| D0191 |
|
336 |
312 |
$0.00 |