| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 99403 |
|
4,871 |
4,522 |
$696K |
| D0120 |
Periodic oral evaluation - established patient |
6,948 |
6,675 |
$339K |
| D0330 |
Panoramic radiographic image |
2,716 |
2,610 |
$330K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
2,338 |
2,000 |
$304K |
| D1110 |
Prophylaxis - adult |
3,924 |
3,767 |
$286K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,301 |
4,142 |
$181K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,830 |
1,437 |
$150K |
| D1351 |
Sealant - per tooth |
10,848 |
3,237 |
$117K |
| D1120 |
Prophylaxis - child |
8,264 |
7,949 |
$107K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,159 |
981 |
$69K |
| 99395 |
Periodic comprehensive preventive medicine reevaluation, established patient, 18-39 years |
479 |
438 |
$67K |
| 99385 |
|
321 |
295 |
$41K |
| D1206 |
Topical application of fluoride varnish |
12,298 |
11,833 |
$27K |
| D7140 |
Extraction, erupted tooth or exposed root |
490 |
322 |
$26K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
2,680 |
2,391 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
2,208 |
2,091 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
89 |
89 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
130 |
111 |
$16K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
263 |
163 |
$15K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
3,872 |
3,480 |
$13K |
| D0191 |
|
1,551 |
1,487 |
$11K |
| D1330 |
|
12,440 |
11,967 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
717 |
685 |
$7K |
| D0272 |
Bitewings - two radiographic images |
4,784 |
4,582 |
$6K |
| D0274 |
Bitewings - four radiographic images |
4,159 |
3,989 |
$6K |
| D3120 |
|
869 |
703 |
$4K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
30 |
27 |
$3K |
| 90670 |
|
743 |
736 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,089 |
595 |
$3K |
| D1354 |
|
828 |
233 |
$2K |
| 99384 |
|
20 |
14 |
$2K |
| 99202 |
Office or other outpatient visit for the evaluation and management of a new patient, straightforward |
23 |
13 |
$2K |
| D4346 |
|
12 |
12 |
$2K |
| D1353 |
|
30 |
14 |
$1K |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
988 |
747 |
$1K |
| 90698 |
|
681 |
676 |
$957.00 |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
20 |
12 |
$954.16 |
| D9999 |
Unspecified adjunctive procedure, by report |
37 |
37 |
$925.00 |
| 90686 |
|
232 |
222 |
$655.00 |
| 90744 |
|
626 |
619 |
$627.00 |
| 90700 |
|
241 |
236 |
$478.50 |
| H0049 |
Alcohol and/or drug screening |
61 |
50 |
$334.27 |
| 90696 |
|
303 |
290 |
$236.50 |
| 90710 |
|
794 |
771 |
$220.00 |
| 99443 |
|
37 |
14 |
$214.67 |
| D1310 |
|
11,456 |
11,001 |
$201.85 |
| 90715 |
|
541 |
526 |
$121.00 |
| 90633 |
|
257 |
247 |
$99.00 |
| 90648 |
|
66 |
66 |
$99.00 |
| D9987 |
|
1,228 |
1,162 |
$0.00 |
| D9986 |
|
2,467 |
2,293 |
$0.00 |
| 90734 |
|
225 |
220 |
$0.00 |
| 90681 |
|
60 |
60 |
$0.00 |
| 90713 |
|
55 |
52 |
$0.00 |
| 90671 |
|
22 |
21 |
$0.00 |
| 90677 |
|
225 |
223 |
$0.00 |
| 90651 |
|
296 |
283 |
$0.00 |