| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
1,243 |
1,164 |
$186K |
| D0120 |
Periodic oral evaluation - established patient |
1,582 |
1,557 |
$82K |
| D1110 |
Prophylaxis - adult |
915 |
906 |
$67K |
| 99403 |
|
402 |
392 |
$62K |
| D0330 |
Panoramic radiographic image |
357 |
354 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
656 |
644 |
$24K |
| D1351 |
Sealant - per tooth |
1,668 |
381 |
$24K |
| D1120 |
Prophylaxis - child |
1,714 |
1,685 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
80 |
$11K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
80 |
76 |
$11K |
| D1206 |
Topical application of fluoride varnish |
2,551 |
2,508 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
63 |
63 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
395 |
383 |
$8K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
1,010 |
922 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
77 |
77 |
$5K |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
891 |
857 |
$5K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
29 |
26 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
41 |
$3K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
447 |
416 |
$3K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
29 |
25 |
$3K |
| D1330 |
|
2,708 |
2,667 |
$3K |
| D0274 |
Bitewings - four radiographic images |
1,273 |
1,262 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
42 |
42 |
$905.00 |
| D0350 |
|
599 |
592 |
$816.11 |
| D0191 |
|
204 |
202 |
$530.40 |
| D0272 |
Bitewings - two radiographic images |
269 |
253 |
$481.12 |
| D0220 |
Intraoral - periapical first radiographic image |
422 |
410 |
$306.72 |
| 90715 |
|
118 |
109 |
$143.01 |
| 90633 |
|
32 |
29 |
$110.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
75 |
51 |
$91.48 |
| 90651 |
|
56 |
48 |
$55.00 |
| 90734 |
|
41 |
36 |
$44.00 |
| D0601 |
|
55 |
55 |
$10.00 |
| D9986 |
|
518 |
509 |
$0.00 |
| D0602 |
|
12 |
12 |
$0.00 |