| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 90460 |
Immunization administration through 18 years of age via any route, first or only component |
1,855 |
1,776 |
$67K |
| D1120 |
Prophylaxis - child |
757 |
757 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,242 |
1,242 |
$23K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
572 |
514 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
504 |
504 |
$12K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
28 |
26 |
$2K |
| 92551 |
|
164 |
153 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
37 |
$843.82 |
| 36415 |
Collection of venous blood by venipuncture |
423 |
374 |
$833.17 |
| 0001A |
|
25 |
19 |
$806.64 |
| 96127 |
|
190 |
178 |
$798.39 |
| 0002A |
|
21 |
17 |
$697.76 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$624.96 |
| D1351 |
Sealant - per tooth |
74 |
14 |
$556.70 |
| 90688 |
|
474 |
467 |
$525.00 |
| 96110 |
Developmental screening, with scoring and documentation, per standardized instrument |
39 |
39 |
$444.33 |
| 99173 |
|
152 |
141 |
$436.04 |
| 90734 |
|
96 |
94 |
$431.64 |
| 90651 |
|
61 |
58 |
$369.70 |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$314.82 |
| 99177 |
|
36 |
34 |
$273.08 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$203.83 |
| 90686 |
|
242 |
239 |
$195.00 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
15 |
12 |
$166.62 |
| 90670 |
|
38 |
29 |
$160.66 |
| D0190 |
|
15 |
15 |
$144.00 |
| 90715 |
|
74 |
70 |
$98.52 |
| 90461 |
|
246 |
235 |
$78.82 |
| 90723 |
|
20 |
13 |
$71.48 |
| 90648 |
|
39 |
30 |
$19.83 |
| 90633 |
|
12 |
12 |
$0.00 |
| 90661 |
|
18 |
18 |
$0.00 |
| 90707 |
|
19 |
15 |
$0.00 |
| 90658 |
|
61 |
61 |
$0.00 |
| D1330 |
|
55 |
54 |
$0.00 |
| 90716 |
|
17 |
13 |
$0.00 |