| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,183 |
2,148 |
$162K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,592 |
2,560 |
$146K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,426 |
1,067 |
$133K |
| D1120 |
Prophylaxis - child |
3,167 |
3,120 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
1,660 |
1,639 |
$82K |
| D1351 |
Sealant - per tooth |
5,770 |
1,417 |
$68K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,496 |
849 |
$66K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,643 |
1,120 |
$57K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
319 |
302 |
$42K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
657 |
637 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
320 |
313 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
2,054 |
1,993 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
1,519 |
1,473 |
$15K |
| D1206 |
Topical application of fluoride varnish |
5,259 |
5,179 |
$13K |
| D0272 |
Bitewings - two radiographic images |
898 |
890 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
72 |
66 |
$9K |
| D0274 |
Bitewings - four radiographic images |
1,151 |
1,129 |
$9K |
| D2330 |
|
87 |
62 |
$6K |
| D1330 |
|
5,500 |
5,418 |
$5K |
| D9999 |
Unspecified adjunctive procedure, by report |
187 |
187 |
$5K |
| D0191 |
|
625 |
605 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
773 |
497 |
$1K |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
192 |
181 |
$1K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
137 |
131 |
$1K |
| D9110 |
|
68 |
65 |
$1K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
200 |
192 |
$1K |
| D0999 |
Unspecified diagnostic procedure, by report |
31 |
31 |
$620.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
138 |
136 |
$22.89 |
| D0601 |
|
233 |
233 |
$14.00 |
| D0602 |
|
12 |
12 |
$0.00 |
| D9986 |
|
1,182 |
1,147 |
$0.00 |
| D9987 |
|
298 |
277 |
$0.00 |
| 90670 |
|
14 |
14 |
$0.00 |