| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
2,002 |
1,980 |
$69K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,351 |
918 |
$62K |
| D1120 |
Prophylaxis - child |
1,913 |
1,901 |
$40K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
1,389 |
1,092 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,537 |
896 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,305 |
2,295 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
665 |
657 |
$20K |
| D1206 |
Topical application of fluoride varnish |
2,807 |
2,788 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
759 |
435 |
$17K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
381 |
302 |
$13K |
| D1351 |
Sealant - per tooth |
1,589 |
548 |
$13K |
| D4341 |
|
1,012 |
425 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
523 |
516 |
$10K |
| D1330 |
|
4,741 |
4,700 |
$9K |
| D1110 |
Prophylaxis - adult |
163 |
161 |
$7K |
| D9999 |
Unspecified adjunctive procedure, by report |
261 |
261 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
390 |
386 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,730 |
1,341 |
$4K |
| D0191 |
|
1,154 |
1,145 |
$3K |
| D1999 |
|
27 |
27 |
$2K |
| D0274 |
Bitewings - four radiographic images |
1,617 |
1,602 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
2,017 |
1,933 |
$1K |
| 99383 |
|
15 |
15 |
$850.80 |
| D4346 |
|
27 |
27 |
$839.32 |
| 99204 |
Office or other outpatient visit for the evaluation and management of a new patient, moderate complexity |
14 |
13 |
$764.36 |
| 99401 |
|
39 |
31 |
$432.90 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$288.66 |
| D0272 |
Bitewings - two radiographic images |
59 |
59 |
$276.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
12 |
12 |
$240.00 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
125 |
101 |
$220.00 |
| 3074F |
|
1,062 |
761 |
$125.03 |
| D0270 |
|
56 |
55 |
$70.15 |
| 3078F |
|
874 |
572 |
$34.29 |
| 96110 |
Developmental screening, with scoring and documentation, per standardized instrument |
169 |
167 |
$16.00 |
| 3008F |
|
2,498 |
1,780 |
$1.68 |
| 1126F |
|
252 |
195 |
$0.00 |
| 1220F |
|
1,175 |
864 |
$0.00 |
| 1170F |
|
26 |
26 |
$0.00 |
| 2000F |
|
1,917 |
1,274 |
$0.00 |
| 1000F |
|
2,061 |
1,373 |
$0.00 |
| 2001F |
|
1,859 |
1,234 |
$0.00 |
| G0447 |
Face-to-face behavioral counseling for obesity, 15 minutes |
414 |
303 |
$0.00 |
| D1320 |
|
352 |
348 |
$0.00 |
| 4000F |
|
114 |
104 |
$0.00 |
| 3079F |
|
402 |
266 |
$0.00 |
| 1111F |
|
13 |
12 |
$0.00 |
| 0513F |
|
132 |
126 |
$0.00 |
| 3044F |
|
18 |
14 |
$0.00 |
| 3080F |
|
23 |
13 |
$0.00 |
| 3075F |
|
16 |
12 |
$0.00 |
| 1160F |
|
1,226 |
877 |
$0.00 |
| 1159F |
|
1,215 |
864 |
$0.00 |
| 0518F |
|
13 |
12 |
$0.00 |
| 90734 |
|
14 |
14 |
$0.00 |
| 90713 |
|
15 |
15 |
$0.00 |
| 4004F |
|
67 |
53 |
$0.00 |
| 3288F |
|
14 |
13 |
$0.00 |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
31 |
31 |
$0.00 |
| 2028F |
|
41 |
25 |
$0.00 |
| 3077F |
|
66 |
41 |
$0.00 |