| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
265 |
240 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
304 |
297 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
127 |
127 |
$10K |
| D1110 |
Prophylaxis - adult |
84 |
83 |
$7K |
| D1120 |
Prophylaxis - child |
407 |
404 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
24 |
$3K |
| D1206 |
Topical application of fluoride varnish |
734 |
723 |
$2K |
| D0240 |
|
91 |
67 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
53 |
$920.53 |
| D1330 |
|
744 |
733 |
$684.42 |
| 90672 |
|
95 |
93 |
$357.52 |
| D0272 |
Bitewings - two radiographic images |
325 |
321 |
$325.52 |
| 90473 |
|
106 |
104 |
$316.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
12 |
12 |
$300.00 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
53 |
45 |
$257.00 |
| D0220 |
Intraoral - periapical first radiographic image |
120 |
119 |
$189.45 |
| D9986 |
|
248 |
238 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$0.00 |