| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 99403 |
|
600 |
560 |
$79K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
114 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
100 |
100 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
243 |
221 |
$5K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
27 |
24 |
$4K |
| 99402 |
|
28 |
26 |
$3K |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$2K |
| D1120 |
Prophylaxis - child |
145 |
145 |
$1K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
262 |
245 |
$1K |
| D1351 |
Sealant - per tooth |
74 |
27 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
14 |
$999.88 |
| D1206 |
Topical application of fluoride varnish |
269 |
269 |
$982.19 |
| D0230 |
Intraoral - periapical each additional radiographic image |
198 |
156 |
$810.75 |
| D0272 |
Bitewings - two radiographic images |
93 |
93 |
$631.27 |
| D0240 |
|
18 |
14 |
$571.32 |
| 90473 |
|
136 |
126 |
$378.40 |
| D9999 |
Unspecified adjunctive procedure, by report |
18 |
18 |
$360.00 |
| 90672 |
|
109 |
102 |
$324.50 |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
56 |
56 |
$322.50 |
| D1330 |
|
269 |
269 |
$261.64 |
| 90686 |
|
83 |
82 |
$121.00 |
| 90715 |
|
31 |
31 |
$110.00 |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
55 |
52 |
$62.47 |
| D9986 |
|
26 |
25 |
$0.00 |
| D0191 |
|
12 |
12 |
$0.00 |