| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
988 |
640 |
$88K |
| D0330 |
Panoramic radiographic image |
918 |
896 |
$67K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
493 |
438 |
$39K |
| D1110 |
Prophylaxis - adult |
888 |
867 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
763 |
749 |
$34K |
| D1120 |
Prophylaxis - child |
1,125 |
1,106 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
720 |
703 |
$30K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
518 |
454 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
647 |
415 |
$23K |
| 99403 |
|
213 |
183 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
410 |
286 |
$18K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
35 |
27 |
$11K |
| D1351 |
Sealant - per tooth |
518 |
174 |
$8K |
| D0190 |
|
1,204 |
1,161 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
39 |
$7K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
866 |
816 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
588 |
540 |
$6K |
| D1206 |
Topical application of fluoride varnish |
1,937 |
1,897 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
299 |
278 |
$4K |
| D0272 |
Bitewings - two radiographic images |
186 |
185 |
$4K |
| D1354 |
|
170 |
33 |
$4K |
| D0274 |
Bitewings - four radiographic images |
738 |
714 |
$3K |
| D1330 |
|
2,130 |
2,089 |
$2K |
| D0350 |
|
305 |
304 |
$2K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
495 |
462 |
$2K |
| D9996 |
|
310 |
306 |
$1K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
43 |
40 |
$1K |
| D1999 |
|
17 |
17 |
$1K |
| 81025 |
|
211 |
197 |
$628.24 |
| D1208 |
Topical application of fluoride, excluding varnish |
63 |
63 |
$456.86 |
| 90715 |
|
60 |
58 |
$122.00 |
| 90651 |
|
117 |
110 |
$103.50 |
| 90686 |
|
19 |
17 |
$72.00 |
| D0603 |
|
442 |
437 |
$69.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$44.80 |
| 90734 |
|
50 |
49 |
$10.00 |
| 90633 |
|
63 |
63 |
$5.00 |
| D0602 |
|
55 |
54 |
$5.00 |
| D9986 |
|
531 |
510 |
$0.00 |
| D0191 |
|
23 |
23 |
$0.00 |
| 3074F |
|
38 |
37 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
17 |
17 |
$0.00 |