| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,969 |
3,957 |
$126K |
| D0120 |
Periodic oral evaluation - established patient |
4,654 |
4,641 |
$106K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
652 |
637 |
$70K |
| D2140 |
|
601 |
592 |
$47K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
1,789 |
1,623 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,739 |
2,725 |
$46K |
| D1351 |
Sealant - per tooth |
1,478 |
667 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,555 |
1,549 |
$43K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
2,174 |
2,034 |
$38K |
| D0272 |
Bitewings - two radiographic images |
2,022 |
2,019 |
$37K |
| D1206 |
Topical application of fluoride varnish |
2,374 |
2,373 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
474 |
368 |
$36K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
3,840 |
3,582 |
$36K |
| D1110 |
Prophylaxis - adult |
1,179 |
1,177 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
3,044 |
3,021 |
$33K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
186 |
177 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
461 |
461 |
$24K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
1,672 |
1,542 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,090 |
1,074 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,701 |
2,620 |
$23K |
| H1000 |
Prenatal care, at-risk assessment |
288 |
287 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
321 |
257 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
460 |
458 |
$15K |
| D9630 |
|
505 |
505 |
$15K |
| D0330 |
Panoramic radiographic image |
448 |
445 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
184 |
112 |
$12K |
| D2160 |
|
114 |
112 |
$10K |
| D7111 |
|
140 |
140 |
$10K |
| 92551 |
|
1,110 |
1,058 |
$6K |
| 99173 |
|
1,101 |
1,020 |
$4K |
| 0012A |
|
228 |
126 |
$4K |
| 0001A |
|
118 |
103 |
$3K |
| 0002A |
|
102 |
91 |
$3K |
| 90686 |
|
926 |
865 |
$3K |
| 99202 |
Office or other outpatient visit for the evaluation and management of a new patient, straightforward |
58 |
54 |
$3K |
| 0011A |
|
260 |
134 |
$2K |
| D0240 |
|
116 |
116 |
$2K |
| 90715 |
|
410 |
377 |
$2K |
| 0071A |
|
45 |
39 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
63 |
63 |
$1K |
| 90651 |
|
416 |
389 |
$1K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
26 |
26 |
$1K |
| 86580 |
|
352 |
332 |
$972.21 |
| 99215 |
Prolong outpt/office vis |
12 |
12 |
$912.25 |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
15 |
12 |
$749.52 |
| 90619 |
|
541 |
508 |
$732.02 |
| 81025 |
|
314 |
303 |
$594.00 |
| 90480 |
|
38 |
19 |
$520.00 |
| 0072A |
|
13 |
13 |
$520.00 |
| 90734 |
|
271 |
236 |
$465.23 |
| 90620 |
|
86 |
82 |
$409.36 |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
24 |
24 |
$390.10 |
| 90656 |
|
32 |
21 |
$245.87 |
| 0064A |
|
40 |
32 |
$120.00 |
| 91301 |
|
265 |
237 |
$41.38 |
| 90670 |
|
55 |
49 |
$10.00 |
| 91300 |
|
56 |
45 |
$0.16 |
| 90633 |
|
231 |
213 |
$0.00 |
| 90710 |
|
196 |
185 |
$0.00 |
| D1999 |
|
44 |
43 |
$0.00 |
| 90707 |
|
14 |
14 |
$0.00 |
| 90700 |
|
29 |
25 |
$0.00 |
| 90696 |
|
179 |
169 |
$0.00 |
| 99000 |
|
82 |
52 |
$0.00 |
| 90647 |
|
31 |
26 |
$0.00 |
| 91306 |
|
21 |
20 |
$0.00 |