| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
92 |
92 |
$10K |
| 90670 |
|
1,017 |
990 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
59 |
$6K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
2,189 |
1,969 |
$6K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
3,049 |
2,872 |
$5K |
| 99403 |
|
26 |
26 |
$3K |
| 90715 |
|
512 |
448 |
$3K |
| 90698 |
|
792 |
771 |
$3K |
| 90696 |
|
399 |
373 |
$2K |
| 90744 |
|
671 |
645 |
$2K |
| 90710 |
|
783 |
741 |
$874.50 |
| D1120 |
Prophylaxis - child |
89 |
89 |
$598.95 |
| 90633 |
|
130 |
115 |
$588.48 |
| D1330 |
|
152 |
152 |
$527.05 |
| 90686 |
|
153 |
150 |
$469.65 |
| 90700 |
|
110 |
108 |
$423.50 |
| D1206 |
Topical application of fluoride varnish |
151 |
151 |
$337.70 |
| 90651 |
|
241 |
212 |
$264.00 |
| D1110 |
Prophylaxis - adult |
58 |
58 |
$251.55 |
| D0274 |
Bitewings - four radiographic images |
61 |
61 |
$132.44 |
| 90734 |
|
74 |
74 |
$99.00 |
| 90681 |
|
104 |
99 |
$93.50 |
| 90648 |
|
25 |
25 |
$49.50 |
| 90474 |
|
29 |
28 |
$38.50 |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
13 |
13 |
$19.50 |
| D0330 |
Panoramic radiographic image |
23 |
23 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
72 |
72 |
$0.00 |
| D1310 |
|
152 |
152 |
$0.00 |