| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
2,288 |
2,263 |
$42K |
| 99401 |
|
1,336 |
1,181 |
$36K |
| 90460 |
Immunization administration through 18 years of age via any route, first or only component |
1,207 |
1,180 |
$32K |
| D0190 |
|
1,430 |
1,408 |
$15K |
| 99391 |
Periodic comprehensive preventive medicine reevaluation, established patient, infant (under 1 year) |
181 |
175 |
$11K |
| 96110 |
Developmental screening, with scoring and documentation, per standardized instrument |
691 |
653 |
$7K |
| 99392 |
Periodic comprehensive preventive medicine reevaluation, established patient, early childhood (1-4 years) |
82 |
81 |
$6K |
| D1120 |
Prophylaxis - child |
151 |
151 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
162 |
159 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
129 |
129 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
25 |
$3K |
| 96372 |
Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular |
149 |
138 |
$2K |
| D0272 |
Bitewings - two radiographic images |
128 |
128 |
$2K |
| 81025 |
|
402 |
362 |
$2K |
| 0001A |
|
39 |
32 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$1K |
| D0330 |
Panoramic radiographic image |
32 |
29 |
$984.54 |
| D0274 |
Bitewings - four radiographic images |
43 |
42 |
$934.15 |
| 92551 |
|
122 |
111 |
$878.78 |
| D0140 |
Limited oral evaluation - problem focused |
37 |
37 |
$873.40 |
| 0002A |
|
23 |
17 |
$766.64 |
| 90651 |
|
50 |
50 |
$554.55 |
| 90686 |
|
719 |
705 |
$480.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
15 |
15 |
$366.00 |
| 96127 |
|
79 |
70 |
$294.26 |
| 99173 |
|
44 |
42 |
$111.38 |
| 90734 |
|
26 |
26 |
$107.91 |
| 90461 |
|
142 |
139 |
$101.34 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
16 |
13 |
$81.66 |
| 90715 |
|
44 |
43 |
$75.22 |
| 36416 |
|
25 |
25 |
$54.94 |
| 85018 |
|
12 |
12 |
$30.55 |
| 36415 |
Collection of venous blood by venipuncture |
15 |
15 |
$24.31 |
| D1330 |
|
41 |
37 |
$0.00 |
| 90674 |
|
147 |
147 |
$0.00 |
| 90619 |
|
13 |
13 |
$0.00 |