| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
10,182 |
10,140 |
$172K |
| D0190 |
|
9,643 |
9,605 |
$95K |
| 90460 |
Immunization administration through 18 years of age via any route, first or only component |
1,080 |
1,036 |
$31K |
| 99391 |
Periodic comprehensive preventive medicine reevaluation, established patient, infant (under 1 year) |
203 |
195 |
$13K |
| D1120 |
Prophylaxis - child |
357 |
355 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
439 |
432 |
$10K |
| 96110 |
Developmental screening, with scoring and documentation, per standardized instrument |
833 |
783 |
$8K |
| 99392 |
Periodic comprehensive preventive medicine reevaluation, established patient, early childhood (1-4 years) |
108 |
107 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
103 |
68 |
$6K |
| D1110 |
Prophylaxis - adult |
135 |
133 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
25 |
$2K |
| D1351 |
Sealant - per tooth |
273 |
79 |
$2K |
| 83655 |
|
144 |
132 |
$2K |
| D0272 |
Bitewings - two radiographic images |
98 |
98 |
$2K |
| D0274 |
Bitewings - four radiographic images |
55 |
53 |
$1K |
| 90686 |
|
667 |
646 |
$715.00 |
| 0002A |
|
17 |
12 |
$552.20 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$317.20 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
26 |
25 |
$191.00 |
| 85018 |
|
75 |
64 |
$173.19 |
| 90715 |
|
42 |
41 |
$150.44 |
| 36416 |
|
77 |
66 |
$137.35 |
| 81025 |
|
17 |
13 |
$81.19 |
| 90461 |
|
168 |
162 |
$0.00 |