| Code | Description | Claims | Beneficiaries | Total Paid |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
2,361 |
2,129 |
$332K |
| D0120 |
Periodic oral evaluation - established patient |
2,662 |
2,599 |
$154K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
1,784 |
1,055 |
$125K |
| 99403 |
|
739 |
681 |
$112K |
| D1120 |
Prophylaxis - child |
4,062 |
3,958 |
$109K |
| D1351 |
Sealant - per tooth |
4,500 |
1,356 |
$76K |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
1,608 |
1,438 |
$72K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
1,127 |
786 |
$69K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
676 |
537 |
$66K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,041 |
999 |
$63K |
| 99203 |
Office or other outpatient visit for the evaluation and management of a new patient, low complexity |
394 |
359 |
$52K |
| D1110 |
Prophylaxis - adult |
759 |
743 |
$43K |
| D0140 |
Limited oral evaluation - problem focused |
1,138 |
1,118 |
$27K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
7,184 |
6,238 |
$25K |
| 99202 |
Office or other outpatient visit for the evaluation and management of a new patient, straightforward |
462 |
330 |
$24K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
4,197 |
3,622 |
$17K |
| 99201 |
|
113 |
99 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
486 |
477 |
$13K |
| D1206 |
Topical application of fluoride varnish |
5,385 |
5,258 |
$10K |
| D1999 |
|
157 |
157 |
$9K |
| 99395 |
Periodic comprehensive preventive medicine reevaluation, established patient, 18-39 years |
69 |
64 |
$9K |
| D0330 |
Panoramic radiographic image |
156 |
156 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
518 |
195 |
$8K |
| D1354 |
|
1,202 |
313 |
$7K |
| D1330 |
|
5,373 |
5,250 |
$5K |
| D0191 |
|
261 |
261 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
37 |
32 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
52 |
52 |
$3K |
| D9996 |
|
2,077 |
2,035 |
$3K |
| 90715 |
|
1,471 |
1,250 |
$3K |
| D9999 |
Unspecified adjunctive procedure, by report |
275 |
275 |
$3K |
| D0999 |
Unspecified diagnostic procedure, by report |
113 |
113 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
18 |
$1K |
| 90723 |
|
130 |
127 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$1K |
| 90686 |
|
504 |
433 |
$1K |
| 90696 |
|
426 |
373 |
$1K |
| D0272 |
Bitewings - two radiographic images |
303 |
294 |
$796.43 |
| 90633 |
|
350 |
329 |
$671.00 |
| D0274 |
Bitewings - four radiographic images |
363 |
356 |
$618.79 |
| 90670 |
|
481 |
445 |
$572.00 |
| 90647 |
|
155 |
150 |
$313.50 |
| 90651 |
|
412 |
384 |
$291.50 |
| 90698 |
|
28 |
27 |
$236.50 |
| D0190 |
|
12 |
12 |
$162.24 |
| 90734 |
|
265 |
244 |
$121.00 |
| 90710 |
|
685 |
591 |
$110.00 |
| 90716 |
|
136 |
124 |
$99.00 |
| 90707 |
|
64 |
54 |
$66.00 |
| 90713 |
|
26 |
26 |
$38.50 |
| 90619 |
|
116 |
112 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
47 |
31 |
$0.00 |
| 90677 |
|
45 |
43 |
$0.00 |
| 90671 |
|
65 |
62 |
$0.00 |