| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,415 |
1,412 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
691 |
458 |
$35K |
| D0330 |
Panoramic radiographic image |
373 |
373 |
$24K |
| D1110 |
Prophylaxis - adult |
466 |
465 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
1,020 |
1,017 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
829 |
829 |
$17K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
398 |
363 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
152 |
152 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
213 |
206 |
$4K |
| D9999 |
Unspecified adjunctive procedure, by report |
170 |
170 |
$4K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
150 |
141 |
$4K |
| 99392 |
Periodic comprehensive preventive medicine reevaluation, established patient, early childhood (1-4 years) |
57 |
55 |
$4K |
| D1206 |
Topical application of fluoride varnish |
1,966 |
1,962 |
$4K |
| 87428 |
|
145 |
139 |
$4K |
| 99391 |
Periodic comprehensive preventive medicine reevaluation, established patient, infant (under 1 year) |
46 |
41 |
$3K |
| D1351 |
Sealant - per tooth |
676 |
218 |
$3K |
| D0274 |
Bitewings - four radiographic images |
460 |
459 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,218 |
627 |
$1K |
| D0272 |
Bitewings - two radiographic images |
843 |
841 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
923 |
913 |
$1K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
29 |
28 |
$1K |
| 90460 |
Immunization administration through 18 years of age via any route, first or only component |
116 |
105 |
$960.00 |
| D1330 |
|
1,967 |
1,962 |
$948.35 |
| 90677 |
|
41 |
39 |
$943.98 |
| 99203 |
Office or other outpatient visit for the evaluation and management of a new patient, low complexity |
25 |
21 |
$867.14 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
14 |
$764.00 |
| 99393 |
Periodic comprehensive preventive medicine reevaluation, established patient, late childhood (5-11 years) |
12 |
12 |
$728.48 |
| 87880 |
Infectious agent antigen detection by immunoassay; Streptococcus, group A |
105 |
99 |
$657.48 |
| D0140 |
Limited oral evaluation - problem focused |
57 |
56 |
$628.14 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
177 |
155 |
$612.00 |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
107 |
91 |
$546.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
16 |
16 |
$530.29 |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
13 |
$185.00 |
| D1354 |
|
41 |
13 |
$112.50 |
| 87807 |
|
12 |
12 |
$85.80 |
| 90686 |
|
91 |
88 |
$23.70 |
| 85018 |
|
15 |
14 |
$14.70 |
| 36415 |
Collection of venous blood by venipuncture |
18 |
18 |
$3.00 |
| 1160F |
|
987 |
877 |
$0.00 |
| 1159F |
|
991 |
882 |
$0.00 |
| 3210F |
|
163 |
146 |
$0.00 |
| 3078F |
|
636 |
572 |
$0.00 |
| 99177 |
|
15 |
13 |
$0.00 |
| 90461 |
|
16 |
16 |
$0.00 |
| 1000F |
|
268 |
245 |
$0.00 |
| 3008F |
|
731 |
651 |
$0.00 |
| 1126F |
|
379 |
352 |
$0.00 |
| 3074F |
|
655 |
590 |
$0.00 |
| 1220F |
|
157 |
145 |
$0.00 |
| 2001F |
|
1,031 |
915 |
$0.00 |
| 2000F |
|
655 |
589 |
$0.00 |
| 90647 |
|
14 |
13 |
$0.00 |
| 92551 |
|
15 |
13 |
$0.00 |
| D3120 |
|
18 |
12 |
$0.00 |