| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,328 |
3,066 |
$359K |
| D1206 |
Topical application of fluoride varnish |
4,012 |
3,682 |
$65K |
| D1110 |
Prophylaxis - adult |
260 |
242 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
326 |
292 |
$31K |
| D1351 |
Sealant - per tooth |
1,379 |
307 |
$24K |
| D0330 |
Panoramic radiographic image |
222 |
203 |
$18K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
376 |
344 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
978 |
918 |
$12K |
| D0274 |
Bitewings - four radiographic images |
465 |
443 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
98 |
57 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
108 |
52 |
$6K |
| 96110 |
Developmental screening, with scoring and documentation, per standardized instrument |
209 |
200 |
$6K |
| 99392 |
Periodic comprehensive preventive medicine reevaluation, established patient, early childhood (1-4 years) |
86 |
78 |
$5K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
238 |
222 |
$4K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
104 |
98 |
$4K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
61 |
55 |
$3K |
| 90837 |
Psychotherapy, 53 minutes with patient |
31 |
21 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
19 |
13 |
$3K |
| D0272 |
Bitewings - two radiographic images |
488 |
474 |
$2K |
| 99391 |
Periodic comprehensive preventive medicine reevaluation, established patient, infant (under 1 year) |
31 |
30 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
43 |
43 |
$2K |
| 99393 |
Periodic comprehensive preventive medicine reevaluation, established patient, late childhood (5-11 years) |
29 |
28 |
$2K |
| 90791 |
Psychiatric diagnostic evaluation |
15 |
15 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
181 |
141 |
$444.22 |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
14 |
13 |
$324.38 |
| 87880 |
Infectious agent antigen detection by immunoassay; Streptococcus, group A |
17 |
16 |
$84.45 |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
26 |
$0.00 |
| D0601 |
|
48 |
47 |
$0.00 |
| D0603 |
|
253 |
201 |
$0.00 |
| D0602 |
|
61 |
59 |
$0.00 |
| 90688 |
|
123 |
114 |
$0.00 |
| 90658 |
|
16 |
16 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
12 |
$0.00 |