| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| H1000 |
Prenatal care, at-risk assessment |
7,547 |
5,046 |
$933K |
| D1351 |
Sealant - per tooth |
2,565 |
941 |
$68K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
328 |
322 |
$43K |
| D1206 |
Topical application of fluoride varnish |
2,482 |
2,462 |
$38K |
| 99403 |
|
191 |
182 |
$25K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
129 |
127 |
$16K |
| D1120 |
Prophylaxis - child |
292 |
285 |
$12K |
| D0191 |
|
2,066 |
2,053 |
$12K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
1,063 |
1,001 |
$8K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
58 |
52 |
$7K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
490 |
473 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
225 |
218 |
$5K |
| D1330 |
|
1,494 |
1,486 |
$5K |
| D9999 |
Unspecified adjunctive procedure, by report |
171 |
171 |
$4K |
| D0190 |
|
94 |
94 |
$2K |
| 99395 |
Periodic comprehensive preventive medicine reevaluation, established patient, 18-39 years |
12 |
12 |
$2K |
| D9996 |
|
309 |
297 |
$917.30 |
| D0350 |
|
133 |
126 |
$738.40 |
| D0999 |
Unspecified diagnostic procedure, by report |
21 |
21 |
$420.00 |
| 90715 |
|
249 |
228 |
$346.50 |
| H0049 |
Alcohol and/or drug screening |
12 |
12 |
$173.24 |
| 90633 |
|
89 |
70 |
$126.50 |
| 90651 |
|
134 |
120 |
$38.50 |
| 90734 |
|
92 |
80 |
$16.50 |
| 90710 |
|
43 |
32 |
$11.00 |
| D0140 |
Limited oral evaluation - problem focused |
81 |
81 |
$0.00 |
| 90696 |
|
17 |
15 |
$0.00 |