| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1003 |
Lpn/lvn services, up to 15 minutes |
38,614 |
17,207 |
$88K |
| D1206 |
Topical application of fluoride varnish |
3,012 |
2,959 |
$53K |
| D1351 |
Sealant - per tooth |
1,979 |
633 |
$46K |
| D0190 |
|
2,989 |
2,941 |
$30K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
398 |
325 |
$20K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
169 |
148 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
52 |
22 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
56 |
$6K |
| D9999 |
Unspecified adjunctive procedure, by report |
111 |
111 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
113 |
104 |
$2K |
| T1002 |
Rn services, up to 15 minutes |
710 |
498 |
$2K |
| D3120 |
|
18 |
12 |
$2K |
| 99403 |
|
14 |
14 |
$2K |
| D1330 |
|
3,026 |
2,973 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
17 |
$834.72 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
16 |
$715.98 |
| 81025 |
|
172 |
162 |
$693.69 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
185 |
140 |
$690.76 |
| D0140 |
Limited oral evaluation - problem focused |
18 |
17 |
$452.63 |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
30 |
27 |
$192.50 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$118.08 |
| 81000 |
|
41 |
41 |
$73.17 |
| 90715 |
|
17 |
17 |
$0.01 |
| D1120 |
Prophylaxis - child |
53 |
48 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
126 |
80 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
22 |
17 |
$0.00 |