| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| G9149 |
National committee for quality assurance - level 2 medical home |
236 |
235 |
$30K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
180 |
171 |
$9K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
85 |
84 |
$5K |
| 90791 |
Psychiatric diagnostic evaluation |
14 |
14 |
$2K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
91 |
90 |
$1K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
15 |
15 |
$314.79 |
| 90480 |
|
15 |
15 |
$193.84 |
| 90656 |
|
41 |
41 |
$102.44 |
| 3078F |
|
12 |
12 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
20 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
69 |
68 |
$0.00 |
| D1110 |
Prophylaxis - adult |
17 |
17 |
$0.00 |
| T1015 |
Clinic visit/encounter, all-inclusive |
206 |
147 |
$0.00 |
| D0330 |
Panoramic radiographic image |
32 |
32 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
33 |
33 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
35 |
33 |
$0.00 |
| 3074F |
|
13 |
12 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
18 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
137 |
50 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
33 |
33 |
$0.00 |