| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 90686 |
|
931 |
898 |
$5K |
| 90715 |
|
139 |
125 |
$2K |
| D1120 |
Prophylaxis - child |
118 |
118 |
$2K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
328 |
247 |
$2K |
| 90619 |
|
237 |
220 |
$2K |
| 81025 |
|
520 |
356 |
$2K |
| D1206 |
Topical application of fluoride varnish |
148 |
148 |
$2K |
| D0272 |
Bitewings - two radiographic images |
95 |
95 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
62 |
58 |
$1K |
| 90734 |
|
230 |
197 |
$958.21 |
| 90656 |
|
116 |
116 |
$936.12 |
| 90710 |
|
37 |
37 |
$751.00 |
| D0120 |
Periodic oral evaluation - established patient |
28 |
26 |
$662.90 |
| D1110 |
Prophylaxis - adult |
18 |
16 |
$466.24 |
| 90651 |
|
57 |
57 |
$368.31 |
| 36415 |
Collection of venous blood by venipuncture |
120 |
110 |
$287.50 |
| D0274 |
Bitewings - four radiographic images |
17 |
15 |
$246.64 |
| 90696 |
|
15 |
15 |
$214.05 |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
23 |
22 |
$153.87 |
| 83655 |
|
13 |
13 |
$139.88 |
| 85018 |
|
48 |
43 |
$87.36 |
| 90633 |
|
23 |
23 |
$80.33 |
| 86580 |
|
154 |
12 |
$66.80 |
| 96372 |
Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular |
114 |
94 |
$59.56 |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
23 |
14 |
$30.00 |
| D0220 |
Intraoral - periapical first radiographic image |
19 |
19 |
$27.20 |
| 87590 |
|
18 |
12 |
$0.00 |
| 87490 |
|
18 |
12 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
18 |
$0.00 |
| A4267 |
Contraceptive supply, condom, male, each |
48 |
28 |
$0.00 |