| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
5,343 |
4,955 |
$742K |
| 99403 |
|
2,121 |
2,016 |
$290K |
| D1351 |
Sealant - per tooth |
6,519 |
1,923 |
$151K |
| D1206 |
Topical application of fluoride varnish |
4,744 |
4,635 |
$75K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
7,595 |
7,216 |
$51K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
10,828 |
10,374 |
$46K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
418 |
301 |
$25K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
327 |
273 |
$24K |
| D0191 |
|
4,428 |
4,328 |
$18K |
| 99201 |
|
107 |
95 |
$12K |
| 90698 |
|
1,717 |
1,663 |
$11K |
| D1110 |
Prophylaxis - adult |
187 |
187 |
$11K |
| D1120 |
Prophylaxis - child |
366 |
366 |
$10K |
| D0330 |
Panoramic radiographic image |
79 |
79 |
$7K |
| 90686 |
|
2,490 |
2,399 |
$7K |
| 99202 |
Office or other outpatient visit for the evaluation and management of a new patient, straightforward |
45 |
43 |
$6K |
| 90474 |
|
1,205 |
1,173 |
$6K |
| D1330 |
|
4,764 |
4,655 |
$6K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
90 |
62 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
481 |
481 |
$5K |
| H1000 |
Prenatal care, at-risk assessment |
31 |
29 |
$5K |
| 90696 |
|
988 |
959 |
$4K |
| 90670 |
|
3,060 |
2,959 |
$4K |
| 90715 |
|
1,175 |
1,138 |
$4K |
| 99402 |
|
29 |
28 |
$3K |
| D9999 |
Unspecified adjunctive procedure, by report |
112 |
112 |
$2K |
| 90710 |
|
1,138 |
1,111 |
$2K |
| 90633 |
|
2,061 |
2,033 |
$2K |
| 90707 |
|
934 |
913 |
$2K |
| 90716 |
|
1,283 |
1,252 |
$2K |
| 90744 |
|
793 |
759 |
$2K |
| 90700 |
|
390 |
384 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
52 |
$1K |
| 90651 |
|
1,384 |
1,343 |
$1K |
| 90647 |
|
300 |
288 |
$1K |
| 90723 |
|
132 |
113 |
$912.10 |
| 90480 |
|
75 |
55 |
$750.00 |
| 90734 |
|
486 |
469 |
$543.00 |
| 91320 |
|
19 |
15 |
$460.00 |
| D0274 |
Bitewings - four radiographic images |
111 |
111 |
$361.00 |
| 90681 |
|
1,188 |
1,158 |
$327.35 |
| D9996 |
|
131 |
131 |
$320.00 |
| D0350 |
|
26 |
26 |
$222.56 |
| 90671 |
|
437 |
421 |
$216.04 |
| 90656 |
|
73 |
73 |
$88.56 |
| 90713 |
|
24 |
24 |
$71.66 |
| 90620 |
|
134 |
131 |
$71.50 |
| D0190 |
|
24 |
24 |
$49.92 |
| 90697 |
|
864 |
840 |
$49.50 |
| D0602 |
|
115 |
115 |
$10.00 |
| D0220 |
Intraoral - periapical first radiographic image |
36 |
36 |
$5.00 |
| D0272 |
Bitewings - two radiographic images |
132 |
132 |
$0.00 |
| D0603 |
|
90 |
90 |
$0.00 |
| D0601 |
|
153 |
153 |
$0.00 |
| 90619 |
|
170 |
166 |
$0.00 |