| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
451 |
451 |
$13K |
| D1206 |
Topical application of fluoride varnish |
636 |
636 |
$10K |
| 90460 |
Immunization administration through 18 years of age via any route, first or only component |
221 |
213 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
349 |
349 |
$8K |
| D0272 |
Bitewings - two radiographic images |
269 |
269 |
$5K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
59 |
52 |
$3K |
| D1351 |
Sealant - per tooth |
310 |
51 |
$2K |
| 81025 |
|
148 |
131 |
$753.49 |
| 36415 |
Collection of venous blood by venipuncture |
424 |
364 |
$710.77 |
| D1354 |
|
109 |
28 |
$629.64 |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$526.56 |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$461.88 |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
12 |
12 |
$343.33 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
52 |
$234.00 |
| 96372 |
Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular |
14 |
13 |
$217.88 |
| 90734 |
|
12 |
12 |
$215.82 |
| 90688 |
|
42 |
34 |
$180.00 |
| 90715 |
|
103 |
97 |
$146.52 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
20 |
17 |
$125.35 |
| D1330 |
|
33 |
33 |
$0.00 |
| 99000 |
|
16 |
14 |
$0.00 |
| 90461 |
|
86 |
85 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$0.00 |