| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
1,595 |
1,544 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
2,242 |
2,143 |
$85K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,626 |
1,146 |
$60K |
| D1110 |
Prophylaxis - adult |
1,416 |
1,398 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
775 |
603 |
$50K |
| D1120 |
Prophylaxis - child |
3,026 |
2,927 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,312 |
1,273 |
$28K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
130 |
128 |
$21K |
| D1351 |
Sealant - per tooth |
2,603 |
875 |
$18K |
| D1206 |
Topical application of fluoride varnish |
4,923 |
4,769 |
$18K |
| D1354 |
|
2,728 |
875 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
936 |
893 |
$6K |
| D0272 |
Bitewings - two radiographic images |
1,972 |
1,900 |
$6K |
| D1330 |
|
5,109 |
4,941 |
$6K |
| H1000 |
Prenatal care, at-risk assessment |
22 |
14 |
$4K |
| D0191 |
|
1,129 |
1,093 |
$3K |
| D0274 |
Bitewings - four radiographic images |
1,482 |
1,433 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
29 |
29 |
$725.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
12 |
12 |
$532.41 |
| D0220 |
Intraoral - periapical first radiographic image |
501 |
484 |
$468.54 |
| 81025 |
|
16 |
14 |
$258.07 |
| 90710 |
|
15 |
15 |
$181.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
292 |
262 |
$138.12 |
| 90670 |
|
20 |
20 |
$121.00 |
| D9996 |
|
167 |
140 |
$120.14 |
| 90633 |
|
26 |
26 |
$104.50 |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
45 |
42 |
$49.50 |
| 90698 |
|
18 |
18 |
$49.50 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
55 |
55 |
$38.50 |
| D0603 |
|
87 |
87 |
$37.00 |
| D0602 |
|
116 |
114 |
$23.00 |
| D0601 |
|
52 |
52 |
$15.00 |
| D9986 |
|
202 |
187 |
$0.00 |