| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
872 |
801 |
$120K |
| D1120 |
Prophylaxis - child |
2,469 |
2,456 |
$120K |
| D0120 |
Periodic oral evaluation - established patient |
2,104 |
2,066 |
$66K |
| 99403 |
|
395 |
379 |
$54K |
| D1206 |
Topical application of fluoride varnish |
2,750 |
2,736 |
$21K |
| D0191 |
|
2,206 |
2,194 |
$18K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
64 |
59 |
$9K |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
205 |
188 |
$8K |
| D1330 |
|
2,847 |
2,833 |
$6K |
| D9999 |
Unspecified adjunctive procedure, by report |
180 |
180 |
$3K |
| D1351 |
Sealant - per tooth |
234 |
57 |
$3K |
| D1999 |
|
34 |
34 |
$2K |
| D0190 |
|
22 |
22 |
$2K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
358 |
333 |
$2K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
14 |
12 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
15 |
13 |
$1K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
147 |
138 |
$946.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
46 |
46 |
$832.83 |
| D0999 |
Unspecified diagnostic procedure, by report |
41 |
41 |
$820.00 |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
16 |
$77.32 |
| 90633 |
|
12 |
12 |
$38.50 |
| 90710 |
|
12 |
12 |
$38.50 |
| 90715 |
|
68 |
62 |
$11.00 |
| 90651 |
|
13 |
12 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
22 |
13 |
$0.00 |