| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,008 |
2,984 |
$123K |
| D0330 |
Panoramic radiographic image |
725 |
723 |
$78K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
699 |
662 |
$78K |
| D1110 |
Prophylaxis - adult |
1,416 |
1,410 |
$76K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
843 |
524 |
$66K |
| D1120 |
Prophylaxis - child |
3,350 |
3,318 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,183 |
1,176 |
$59K |
| D1206 |
Topical application of fluoride varnish |
6,248 |
6,186 |
$55K |
| D1351 |
Sealant - per tooth |
3,941 |
1,134 |
$55K |
| 99403 |
|
388 |
378 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
556 |
322 |
$25K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
2,703 |
2,634 |
$14K |
| D0191 |
|
995 |
994 |
$13K |
| D1330 |
|
6,425 |
6,363 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
780 |
768 |
$8K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
1,379 |
1,360 |
$8K |
| D0272 |
Bitewings - two radiographic images |
1,077 |
1,068 |
$8K |
| D0190 |
|
1,457 |
1,433 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
725 |
713 |
$5K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
28 |
26 |
$4K |
| D0274 |
Bitewings - four radiographic images |
727 |
723 |
$4K |
| 90686 |
|
413 |
408 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
78 |
78 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
24 |
$1K |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
365 |
359 |
$984.44 |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
25 |
$808.78 |
| D2330 |
|
12 |
12 |
$782.07 |
| D0999 |
Unspecified diagnostic procedure, by report |
36 |
36 |
$720.00 |
| D1999 |
|
13 |
13 |
$720.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$640.76 |
| 90715 |
|
304 |
300 |
$354.30 |
| D0601 |
|
717 |
717 |
$343.00 |
| 90670 |
|
438 |
431 |
$170.50 |
| 90723 |
|
66 |
65 |
$143.00 |
| 90647 |
|
73 |
73 |
$104.50 |
| 90710 |
|
110 |
109 |
$55.00 |
| 90633 |
|
12 |
12 |
$16.50 |
| D0602 |
|
202 |
202 |
$4.00 |
| D0603 |
|
83 |
83 |
$0.00 |
| 90697 |
|
86 |
83 |
$0.00 |
| 90716 |
|
18 |
17 |
$0.00 |
| 90677 |
|
30 |
30 |
$0.00 |
| D9986 |
|
975 |
960 |
$0.00 |
| 90671 |
|
55 |
53 |
$0.00 |