| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,643 |
1,608 |
$105K |
| D1110 |
Prophylaxis - adult |
754 |
752 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
554 |
550 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
546 |
413 |
$47K |
| D0140 |
Limited oral evaluation - problem focused |
836 |
822 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
206 |
152 |
$11K |
| D0330 |
Panoramic radiographic image |
67 |
67 |
$9K |
| D1120 |
Prophylaxis - child |
1,562 |
1,547 |
$8K |
| D1206 |
Topical application of fluoride varnish |
2,401 |
2,384 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
650 |
639 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
29 |
$3K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
16 |
13 |
$2K |
| D1351 |
Sealant - per tooth |
109 |
26 |
$2K |
| D0272 |
Bitewings - two radiographic images |
1,425 |
1,418 |
$2K |
| D1330 |
|
2,459 |
2,442 |
$2K |
| D0240 |
|
114 |
92 |
$2K |
| 99403 |
|
13 |
12 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
80 |
80 |
$2K |
| D0274 |
Bitewings - four radiographic images |
398 |
396 |
$996.30 |
| D1999 |
|
14 |
14 |
$820.00 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
139 |
111 |
$552.00 |
| 90672 |
|
106 |
104 |
$467.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
63 |
34 |
$372.53 |
| 90473 |
|
119 |
118 |
$249.00 |
| 90686 |
|
30 |
29 |
$115.50 |
| D9986 |
|
521 |
512 |
$0.00 |