| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| H0004 |
Behavioral health counseling and therapy, per 15 minutes |
236 |
219 |
$37K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
3,850 |
3,465 |
$31K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
1,805 |
1,770 |
$19K |
| T1015 |
Clinic visit/encounter, all-inclusive |
243 |
228 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
185 |
185 |
$7K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
483 |
476 |
$5K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
316 |
296 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
91 |
91 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
52 |
$3K |
| D1110 |
Prophylaxis - adult |
71 |
71 |
$3K |
| 99392 |
Periodic comprehensive preventive medicine reevaluation, established patient, early childhood (1-4 years) |
109 |
109 |
$2K |
| D0274 |
Bitewings - four radiographic images |
101 |
101 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
25 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
24 |
$962.49 |
| D1120 |
Prophylaxis - child |
58 |
58 |
$822.82 |
| 99393 |
Periodic comprehensive preventive medicine reevaluation, established patient, late childhood (5-11 years) |
51 |
51 |
$780.36 |
| 90686 |
|
536 |
534 |
$725.29 |
| 99391 |
Periodic comprehensive preventive medicine reevaluation, established patient, infant (under 1 year) |
54 |
51 |
$664.54 |
| 87426 |
Infectious agent antigen detection, SARS-CoV-2 (COVID-19) |
19 |
17 |
$488.52 |
| D0140 |
Limited oral evaluation - problem focused |
46 |
46 |
$478.93 |
| 99394 |
Periodic comprehensive preventive medicine reevaluation, established patient, adolescent (12-17 years) |
25 |
25 |
$158.67 |
| D0120 |
Periodic oral evaluation - established patient |
27 |
27 |
$136.37 |
| D1330 |
|
353 |
348 |
$117.00 |
| 90647 |
|
12 |
12 |
$66.56 |
| 90723 |
|
14 |
14 |
$41.60 |
| D1206 |
Topical application of fluoride varnish |
182 |
182 |
$25.27 |
| 90670 |
|
29 |
29 |
$0.00 |
| 87804 |
Infectious agent antigen detection by immunoassay; Influenza, each type |
126 |
124 |
$0.00 |
| 87880 |
Infectious agent antigen detection by immunoassay; Streptococcus, group A |
63 |
63 |
$0.00 |
| 99188 |
|
73 |
68 |
$0.00 |
| 90734 |
|
12 |
12 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
146 |
146 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
65 |
41 |
$0.00 |
| 85018 |
|
165 |
165 |
$0.00 |
| 36416 |
|
118 |
117 |
$0.00 |
| 87807 |
|
13 |
12 |
$0.00 |