| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,649 |
836 |
$60K |
| D0191 |
|
1,699 |
1,697 |
$35K |
| D1330 |
|
2,465 |
2,456 |
$24K |
| D1120 |
Prophylaxis - child |
454 |
450 |
$15K |
| H1000 |
Prenatal care, at-risk assessment |
110 |
98 |
$14K |
| D1206 |
Topical application of fluoride varnish |
2,454 |
2,445 |
$14K |
| D1110 |
Prophylaxis - adult |
211 |
211 |
$10K |
| 99403 |
|
83 |
77 |
$10K |
| D9999 |
Unspecified adjunctive procedure, by report |
370 |
370 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
187 |
187 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
528 |
524 |
$4K |
| D0272 |
Bitewings - two radiographic images |
259 |
255 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
91 |
89 |
$2K |
| D0274 |
Bitewings - four radiographic images |
136 |
136 |
$2K |
| D0190 |
|
94 |
94 |
$1K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
226 |
116 |
$658.50 |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
148 |
67 |
$652.00 |
| D2140 |
|
12 |
12 |
$517.84 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
12 |
$506.73 |
| 90686 |
|
98 |
60 |
$33.32 |
| 90670 |
|
25 |
13 |
$0.00 |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
64 |
59 |
$0.00 |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
637 |
573 |
$0.00 |
| 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 |
1,017 |
895 |
$0.00 |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
289 |
276 |
$0.00 |
| 90723 |
|
24 |
12 |
$0.00 |