| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
756 |
602 |
$74K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
146 |
146 |
$21K |
| D1120 |
Prophylaxis - child |
54 |
54 |
$10K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
50 |
43 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
21 |
21 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
15 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
14 |
$2K |
| D1351 |
Sealant - per tooth |
57 |
26 |
$757.84 |
| 90656 |
|
30 |
30 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
31 |
31 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
54 |
54 |
$0.00 |
| 99177 |
|
19 |
13 |
$0.00 |