| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,355 |
728 |
$67K |
| D1206 |
Topical application of fluoride varnish |
2,833 |
2,824 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
781 |
781 |
$38K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
224 |
214 |
$33K |
| D0191 |
|
2,911 |
2,896 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
236 |
236 |
$10K |
| D1330 |
|
3,174 |
3,164 |
$8K |
| D1120 |
Prophylaxis - child |
797 |
797 |
$6K |
| D0190 |
|
419 |
415 |
$4K |
| D0272 |
Bitewings - two radiographic images |
82 |
82 |
$351.00 |
| D1355 |
|
22 |
12 |
$133.19 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
43 |
41 |
$110.00 |
| 90715 |
|
15 |
13 |
$49.50 |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
15 |
12 |
$36.36 |