| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
9,718 |
9,097 |
$490K |
| D0120 |
Periodic oral evaluation - established patient |
9,540 |
8,475 |
$424K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
4,092 |
3,714 |
$402K |
| D0330 |
Panoramic radiographic image |
4,005 |
3,779 |
$356K |
| H1000 |
Prenatal care, at-risk assessment |
3,471 |
2,663 |
$351K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
8,834 |
8,052 |
$317K |
| 99391 |
Periodic comprehensive preventive medicine reevaluation, established patient, infant (under 1 year) |
3,186 |
3,000 |
$270K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,109 |
2,232 |
$234K |
| 99403 |
|
2,098 |
1,941 |
$197K |
| D1110 |
Prophylaxis - adult |
4,941 |
4,395 |
$186K |
| 99392 |
Periodic comprehensive preventive medicine reevaluation, established patient, early childhood (1-4 years) |
1,647 |
1,600 |
$128K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
2,351 |
2,009 |
$118K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
18,745 |
18,060 |
$110K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,960 |
1,554 |
$110K |
| D1351 |
Sealant - per tooth |
9,118 |
2,282 |
$98K |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
2,131 |
2,002 |
$79K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
13,450 |
12,694 |
$74K |
| D1120 |
Prophylaxis - child |
14,010 |
12,888 |
$69K |
| 99203 |
Office or other outpatient visit for the evaluation and management of a new patient, low complexity |
572 |
538 |
$59K |
| D1206 |
Topical application of fluoride varnish |
18,734 |
17,088 |
$52K |
| 99393 |
Periodic comprehensive preventive medicine reevaluation, established patient, late childhood (5-11 years) |
489 |
487 |
$50K |
| 99381 |
|
336 |
303 |
$41K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
257 |
158 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
169 |
169 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
3,142 |
2,699 |
$25K |
| D1330 |
|
19,275 |
17,599 |
$22K |
| D1999 |
|
293 |
293 |
$17K |
| D0272 |
Bitewings - two radiographic images |
6,637 |
6,005 |
$14K |
| D9999 |
Unspecified adjunctive procedure, by report |
768 |
745 |
$12K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
172 |
157 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
84 |
40 |
$11K |
| 90698 |
|
1,205 |
1,155 |
$11K |
| 90686 |
|
2,319 |
2,267 |
$10K |
| 99395 |
Periodic comprehensive preventive medicine reevaluation, established patient, 18-39 years |
90 |
81 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
330 |
189 |
$9K |
| D0274 |
Bitewings - four radiographic images |
4,813 |
4,259 |
$8K |
| 90715 |
|
1,849 |
1,816 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
658 |
582 |
$8K |
| 90696 |
|
1,295 |
1,258 |
$7K |
| 99394 |
Periodic comprehensive preventive medicine reevaluation, established patient, adolescent (12-17 years) |
78 |
78 |
$6K |
| 90670 |
|
2,251 |
2,172 |
$6K |
| 90723 |
|
315 |
314 |
$3K |
| J7307 |
Etonogestrel (contraceptive) implant system, including implant and supplies |
12 |
12 |
$3K |
| 90633 |
|
2,546 |
2,497 |
$3K |
| 90651 |
|
1,791 |
1,747 |
$2K |
| D0603 |
|
1,532 |
1,503 |
$2K |
| 90700 |
|
313 |
311 |
$2K |
| 90710 |
|
2,325 |
2,261 |
$2K |
| 99204 |
Office or other outpatient visit for the evaluation and management of a new patient, moderate complexity |
12 |
12 |
$1K |
| D0601 |
|
1,451 |
1,438 |
$1K |
| 90473 |
|
344 |
337 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,037 |
747 |
$1K |
| 90734 |
|
862 |
835 |
$784.77 |
| 90744 |
|
569 |
552 |
$621.50 |
| 90647 |
|
233 |
231 |
$580.00 |
| D0602 |
|
339 |
336 |
$458.00 |
| 90681 |
|
913 |
875 |
$320.47 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
86 |
40 |
$274.69 |
| D0191 |
|
12 |
12 |
$268.19 |
| 90658 |
|
42 |
42 |
$193.00 |
| 90716 |
|
497 |
495 |
$140.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
77 |
77 |
$100.00 |
| 99441 |
|
19 |
18 |
$99.55 |
| D1208 |
Topical application of fluoride, excluding varnish |
337 |
328 |
$77.34 |
| 90620 |
|
89 |
83 |
$42.50 |
| 90707 |
|
161 |
161 |
$30.00 |
| 90619 |
|
381 |
378 |
$16.50 |
| 90697 |
|
984 |
960 |
$11.00 |
| 90713 |
|
413 |
408 |
$5.50 |
| 36415 |
Collection of venous blood by venipuncture |
351 |
300 |
$4.20 |
| 90656 |
|
146 |
146 |
$0.00 |
| D9986 |
|
6,252 |
5,344 |
$0.00 |
| 90671 |
|
917 |
902 |
$0.00 |
| D9987 |
|
27 |
13 |
$0.00 |