| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
2,465 |
2,125 |
$100K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
2,551 |
2,292 |
$86K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
854 |
753 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
328 |
152 |
$22K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
1,667 |
1,498 |
$19K |
| D0330 |
Panoramic radiographic image |
676 |
596 |
$18K |
| 87637 |
Infectious agent detection by nucleic acid; SARS-CoV-2, influenza, and RSV |
119 |
113 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
165 |
129 |
$13K |
| 90834 |
Psychotherapy, 45 minutes with patient |
313 |
205 |
$13K |
| D1206 |
Topical application of fluoride varnish |
561 |
541 |
$12K |
| D1110 |
Prophylaxis - adult |
241 |
233 |
$10K |
| D1120 |
Prophylaxis - child |
264 |
256 |
$9K |
| D0274 |
Bitewings - four radiographic images |
510 |
439 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
116 |
102 |
$8K |
| 99391 |
Periodic comprehensive preventive medicine reevaluation, established patient, infant (under 1 year) |
106 |
97 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
225 |
210 |
$5K |
| 99393 |
Periodic comprehensive preventive medicine reevaluation, established patient, late childhood (5-11 years) |
73 |
70 |
$5K |
| A0425 |
Ground mileage, per statute mile |
540 |
227 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
372 |
343 |
$4K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
212 |
191 |
$3K |
| 92551 |
|
390 |
355 |
$2K |
| 91320 |
|
20 |
18 |
$2K |
| A0110 |
Non-emergency transportation and bus, intra or inter state carrier |
690 |
274 |
$2K |
| 36415 |
Collection of venous blood by venipuncture |
1,658 |
1,401 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
392 |
145 |
$2K |
| 90686 |
|
507 |
473 |
$2K |
| 90656 |
|
96 |
83 |
$1K |
| D0272 |
Bitewings - two radiographic images |
74 |
74 |
$1K |
| 99392 |
Periodic comprehensive preventive medicine reevaluation, established patient, early childhood (1-4 years) |
16 |
13 |
$1K |
| 99394 |
Periodic comprehensive preventive medicine reevaluation, established patient, adolescent (12-17 years) |
14 |
14 |
$1K |
| 87804 |
Infectious agent antigen detection by immunoassay; Influenza, each type |
111 |
108 |
$1K |
| 99173 |
|
234 |
221 |
$965.85 |
| 90677 |
|
16 |
13 |
$865.98 |
| 99177 |
|
186 |
155 |
$774.83 |
| A0100 |
Non-emergency transportation; taxi |
607 |
238 |
$699.38 |
| 87880 |
Infectious agent antigen detection by immunoassay; Streptococcus, group A |
69 |
67 |
$568.28 |
| 90688 |
|
53 |
49 |
$384.14 |
| 90480 |
|
18 |
17 |
$284.00 |
| 3074F |
|
1,241 |
1,076 |
$250.00 |
| 3078F |
|
991 |
849 |
$190.00 |
| 3008F |
|
1,339 |
1,143 |
$100.00 |
| 3079F |
|
80 |
68 |
$40.00 |
| 90674 |
|
71 |
61 |
$0.00 |
| 0501F |
|
138 |
77 |
$0.00 |
| D0603 |
|
18 |
12 |
$0.00 |
| G0439 |
Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit |
19 |
13 |
$0.00 |
| 0502F |
|
445 |
278 |
$0.00 |
| 90648 |
|
14 |
12 |
$0.00 |