| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
1,582 |
1,427 |
$51K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
2,003 |
1,753 |
$45K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
93 |
93 |
$5K |
| D1120 |
Prophylaxis - child |
69 |
69 |
$5K |
| D1206 |
Topical application of fluoride varnish |
178 |
178 |
$4K |
| D1351 |
Sealant - per tooth |
218 |
53 |
$2K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
297 |
296 |
$2K |
| D0191 |
|
53 |
53 |
$973.44 |
| 90686 |
|
164 |
162 |
$667.22 |
| D1330 |
|
197 |
197 |
$594.22 |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
35 |
32 |
$593.54 |
| 90473 |
|
36 |
36 |
$294.00 |
| G0008 |
Administration of influenza virus vaccine |
26 |
26 |
$166.19 |
| 90715 |
|
26 |
26 |
$119.00 |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
13 |
13 |
$100.00 |
| 81025 |
|
12 |
12 |
$31.56 |
| 1160F |
|
13 |
13 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
23 |
23 |
$0.00 |
| 1170F |
|
27 |
26 |
$0.00 |
| 3074F |
|
14 |
14 |
$0.00 |
| 90660 |
|
13 |
13 |
$0.00 |