| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 99403 |
|
5,178 |
5,023 |
$703K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
2,176 |
2,085 |
$327K |
| D0120 |
Periodic oral evaluation - established patient |
3,170 |
3,091 |
$175K |
| D1110 |
Prophylaxis - adult |
2,395 |
2,356 |
$134K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,547 |
2,508 |
$130K |
| D0330 |
Panoramic radiographic image |
1,183 |
1,173 |
$129K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,090 |
864 |
$119K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,609 |
1,199 |
$119K |
| D1120 |
Prophylaxis - child |
5,555 |
5,458 |
$112K |
| D1351 |
Sealant - per tooth |
4,923 |
1,310 |
$65K |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
1,566 |
1,513 |
$62K |
| D1206 |
Topical application of fluoride varnish |
9,210 |
9,051 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
176 |
176 |
$18K |
| D0145 |
Oral evaluation for a patient under three years of age |
245 |
243 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
889 |
864 |
$15K |
| D0191 |
|
2,164 |
2,135 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
618 |
538 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
575 |
559 |
$9K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
1,797 |
1,697 |
$8K |
| D9999 |
Unspecified adjunctive procedure, by report |
369 |
369 |
$8K |
| D1330 |
|
7,929 |
7,793 |
$6K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
890 |
819 |
$4K |
| D1999 |
|
46 |
46 |
$3K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
18 |
16 |
$2K |
| D0272 |
Bitewings - two radiographic images |
1,357 |
1,319 |
$949.29 |
| D0274 |
Bitewings - four radiographic images |
2,499 |
2,435 |
$938.24 |
| 90686 |
|
90 |
89 |
$617.10 |
| 90651 |
|
81 |
80 |
$484.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
23 |
23 |
$460.00 |
| 90715 |
|
268 |
264 |
$389.47 |
| 90696 |
|
79 |
78 |
$377.30 |
| 90633 |
|
37 |
37 |
$230.99 |
| 90670 |
|
69 |
68 |
$170.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
13 |
$169.90 |
| D3120 |
|
154 |
130 |
$111.20 |
| 90734 |
|
64 |
61 |
$99.00 |
| 90698 |
|
12 |
12 |
$55.00 |
| 90710 |
|
84 |
83 |
$0.00 |
| D9986 |
|
80 |
76 |
$0.00 |