| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,145 |
1,136 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,490 |
1,469 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
950 |
950 |
$13K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
858 |
812 |
$13K |
| D1110 |
Prophylaxis - adult |
165 |
165 |
$9K |
| D0272 |
Bitewings - two radiographic images |
217 |
217 |
$3K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
118 |
118 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
46 |
38 |
$1K |
| 90460 |
Immunization administration through 18 years of age via any route, first or only component |
46 |
42 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
14 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
69 |
69 |
$952.00 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
14 |
14 |
$922.00 |
| 86580 |
|
163 |
157 |
$815.39 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$689.86 |
| D1206 |
Topical application of fluoride varnish |
19 |
19 |
$570.00 |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
54 |
$558.00 |
| 90707 |
|
13 |
13 |
$545.95 |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
17 |
15 |
$517.56 |
| D1330 |
|
1,054 |
1,045 |
$419.40 |
| 90734 |
|
131 |
130 |
$367.85 |
| G0435 |
Infectious agent antibody detection by rapid antibody test, hiv-1 and/or hiv-2, screening |
40 |
40 |
$203.24 |
| 36415 |
Collection of venous blood by venipuncture |
419 |
405 |
$85.94 |
| 90713 |
|
38 |
38 |
$37.00 |
| 90715 |
|
33 |
33 |
$36.00 |
| 90686 |
|
15 |
15 |
$19.03 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
130 |
127 |
$0.00 |