| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
6,354 |
6,068 |
$330K |
| D1110 |
Prophylaxis - adult |
2,407 |
2,328 |
$138K |
| D1351 |
Sealant - per tooth |
6,581 |
1,701 |
$112K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
3,170 |
2,641 |
$104K |
| T1003 |
Lpn/lvn services, up to 15 minutes |
42,226 |
18,688 |
$67K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,308 |
1,258 |
$54K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
980 |
912 |
$45K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
1,777 |
1,388 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
3,122 |
2,984 |
$31K |
| D1120 |
Prophylaxis - child |
5,373 |
5,127 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
377 |
299 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
390 |
315 |
$20K |
| D1206 |
Topical application of fluoride varnish |
6,844 |
6,552 |
$19K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
1,062 |
1,033 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
270 |
270 |
$17K |
| T1002 |
Rn services, up to 15 minutes |
4,884 |
2,918 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
409 |
228 |
$15K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
1,839 |
1,793 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
1,266 |
1,212 |
$13K |
| D0274 |
Bitewings - four radiographic images |
1,781 |
1,748 |
$8K |
| D1354 |
|
849 |
347 |
$8K |
| D1330 |
|
7,777 |
7,440 |
$6K |
| D9999 |
Unspecified adjunctive procedure, by report |
325 |
325 |
$4K |
| 99392 |
Periodic comprehensive preventive medicine reevaluation, established patient, early childhood (1-4 years) |
41 |
41 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
41 |
41 |
$3K |
| D1999 |
|
46 |
46 |
$3K |
| 99215 |
Prolong outpt/office vis |
44 |
42 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,981 |
1,827 |
$2K |
| D0272 |
Bitewings - two radiographic images |
366 |
365 |
$2K |
| D9996 |
|
164 |
164 |
$1K |
| D9310 |
|
101 |
100 |
$1K |
| 99391 |
Periodic comprehensive preventive medicine reevaluation, established patient, infant (under 1 year) |
13 |
12 |
$1K |
| 85018 |
|
626 |
621 |
$968.06 |
| 90686 |
|
319 |
315 |
$705.45 |
| 87428 |
|
13 |
13 |
$430.08 |
| 90677 |
|
72 |
72 |
$250.00 |
| D0330 |
Panoramic radiographic image |
126 |
126 |
$203.03 |
| 87254 |
|
30 |
27 |
$130.87 |
| 90670 |
|
191 |
189 |
$120.00 |
| D9215 |
|
650 |
632 |
$56.18 |
| D1208 |
Topical application of fluoride, excluding varnish |
130 |
117 |
$31.81 |
| 90715 |
|
51 |
48 |
$0.00 |
| 90633 |
|
43 |
43 |
$0.00 |
| 90647 |
|
40 |
39 |
$0.00 |
| 90656 |
|
29 |
29 |
$0.00 |
| 90723 |
|
14 |
13 |
$0.00 |
| 36416 |
|
118 |
90 |
$0.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
118 |
117 |
$0.00 |