| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
1,919 |
1,737 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
590 |
552 |
$23K |
| D1120 |
Prophylaxis - child |
608 |
589 |
$18K |
| D1110 |
Prophylaxis - adult |
144 |
144 |
$8K |
| D1351 |
Sealant - per tooth |
516 |
140 |
$7K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
197 |
189 |
$7K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
562 |
542 |
$6K |
| D1206 |
Topical application of fluoride varnish |
751 |
727 |
$5K |
| D0190 |
|
601 |
577 |
$5K |
| D1330 |
|
797 |
773 |
$2K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
271 |
262 |
$2K |
| 99392 |
Periodic comprehensive preventive medicine reevaluation, established patient, early childhood (1-4 years) |
13 |
13 |
$807.09 |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
12 |
12 |
$440.76 |
| 87804 |
Infectious agent antigen detection by immunoassay; Influenza, each type |
15 |
15 |
$171.67 |
| 90686 |
|
33 |
33 |
$30.00 |
| 90715 |
|
15 |
14 |
$10.00 |
| 90696 |
|
12 |
12 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$0.00 |
| 90710 |
|
13 |
13 |
$0.00 |
| 90670 |
|
30 |
26 |
$0.00 |