| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
2,889 |
2,846 |
$198K |
| D1120 |
Prophylaxis - child |
826 |
816 |
$85K |
| D1110 |
Prophylaxis - adult |
458 |
453 |
$46K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
403 |
379 |
$43K |
| D0140 |
Limited oral evaluation - problem focused |
118 |
117 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
176 |
174 |
$8K |
| D0330 |
Panoramic radiographic image |
60 |
60 |
$6K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
125 |
124 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
81 |
80 |
$6K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
54 |
52 |
$5K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
65 |
65 |
$5K |
| D1351 |
Sealant - per tooth |
765 |
163 |
$3K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
18 |
18 |
$2K |
| D0274 |
Bitewings - four radiographic images |
55 |
54 |
$1K |
| 99393 |
Periodic comprehensive preventive medicine reevaluation, established patient, late childhood (5-11 years) |
20 |
20 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
196 |
193 |
$1K |
| 99394 |
Periodic comprehensive preventive medicine reevaluation, established patient, adolescent (12-17 years) |
12 |
12 |
$379.50 |
| 99391 |
Periodic comprehensive preventive medicine reevaluation, established patient, infant (under 1 year) |
15 |
14 |
$253.00 |
| 96372 |
Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular |
12 |
12 |
$126.50 |
| G0467 |
Federally qualified health center (fqhc) visit, established patient; a medically-necessary, face-to-face encounter (one-on-one) between an established patient and a fqhc practitioner during which time one or more fqhc services are rendered and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving a fqhc visit |
49 |
46 |
$49.16 |
| D0191 |
|
123 |
121 |
$0.00 |
| 90670 |
|
31 |
31 |
$0.00 |
| 99173 |
|
32 |
32 |
$0.00 |
| 90723 |
|
27 |
27 |
$0.00 |
| 36415 |
Collection of venous blood by venipuncture |
63 |
57 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$0.00 |
| 94760 |
|
58 |
55 |
$0.00 |
| 90686 |
|
28 |
28 |
$0.00 |
| 90680 |
|
13 |
13 |
$0.00 |
| 92551 |
|
34 |
34 |
$0.00 |