| Code | Description | Claims | Beneficiaries | Total Paid |
| H1000 |
Prenatal care, at-risk assessment |
1,771 |
1,171 |
$268K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
681 |
627 |
$99K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
347 |
298 |
$31K |
| D1206 |
Topical application of fluoride varnish |
896 |
881 |
$22K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
2,759 |
2,615 |
$19K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
277 |
174 |
$15K |
| D0191 |
|
660 |
646 |
$14K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
108 |
95 |
$13K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
1,695 |
1,479 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
187 |
187 |
$11K |
| 99395 |
Periodic comprehensive preventive medicine reevaluation, established patient, 18-39 years |
38 |
38 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
131 |
128 |
$5K |
| 99385 |
|
26 |
26 |
$4K |
| D1351 |
Sealant - per tooth |
594 |
157 |
$3K |
| 99443 |
|
54 |
28 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$2K |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
28 |
28 |
$1K |
| 99215 |
Prolong outpt/office vis |
15 |
14 |
$1K |
| D1110 |
Prophylaxis - adult |
58 |
56 |
$1K |
| D1120 |
Prophylaxis - child |
110 |
110 |
$1K |
| D9999 |
Unspecified adjunctive procedure, by report |
51 |
51 |
$1K |
| 90715 |
|
563 |
532 |
$976.90 |
| D1330 |
|
801 |
789 |
$740.94 |
| 90696 |
|
58 |
57 |
$328.00 |
| 90633 |
|
119 |
114 |
$240.00 |
| 90686 |
|
66 |
65 |
$209.00 |
| 90651 |
|
158 |
150 |
$198.00 |
| D0272 |
Bitewings - two radiographic images |
143 |
143 |
$119.81 |
| 90710 |
|
137 |
132 |
$117.00 |
| 90734 |
|
111 |
102 |
$90.50 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
177 |
173 |
$0.00 |
| 90619 |
|
14 |
14 |
$0.00 |