| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,113 |
2,087 |
$127K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
1,870 |
1,591 |
$122K |
| D0120 |
Periodic oral evaluation - established patient |
2,286 |
2,180 |
$83K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
688 |
645 |
$65K |
| D1110 |
Prophylaxis - adult |
590 |
589 |
$46K |
| D0190 |
|
2,819 |
2,787 |
$43K |
| D9996 |
|
1,169 |
1,163 |
$17K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
157 |
128 |
$11K |
| D1206 |
Topical application of fluoride varnish |
2,737 |
2,706 |
$10K |
| D1351 |
Sealant - per tooth |
2,003 |
610 |
$8K |
| 99403 |
|
40 |
36 |
$5K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
607 |
585 |
$5K |
| D1330 |
|
2,875 |
2,844 |
$3K |
| D1999 |
|
48 |
48 |
$3K |
| D9999 |
Unspecified adjunctive procedure, by report |
163 |
163 |
$3K |
| D0350 |
|
561 |
557 |
$3K |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
141 |
132 |
$3K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
232 |
225 |
$1K |
| 90686 |
|
215 |
211 |
$1K |
| 81025 |
|
253 |
246 |
$464.12 |
| D0999 |
Unspecified diagnostic procedure, by report |
20 |
20 |
$400.00 |
| 90715 |
|
94 |
92 |
$377.50 |
| 90651 |
|
102 |
100 |
$112.00 |
| 90633 |
|
49 |
49 |
$87.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
114 |
114 |
$79.07 |
| 90734 |
|
76 |
75 |
$38.50 |
| 3078F |
|
87 |
82 |
$0.00 |
| 3077F |
|
13 |
12 |
$0.00 |
| 3074F |
|
70 |
62 |
$0.00 |
| 3079F |
|
16 |
13 |
$0.00 |