| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
1,923 |
1,754 |
$93K |
| D1120 |
Prophylaxis - child |
939 |
932 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
899 |
897 |
$26K |
| D1110 |
Prophylaxis - adult |
317 |
317 |
$23K |
| D1351 |
Sealant - per tooth |
776 |
202 |
$11K |
| D0190 |
|
993 |
992 |
$9K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
198 |
188 |
$8K |
| D1206 |
Topical application of fluoride varnish |
1,211 |
1,204 |
$7K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
483 |
466 |
$5K |
| D1330 |
|
1,291 |
1,284 |
$3K |
| 99392 |
Periodic comprehensive preventive medicine reevaluation, established patient, early childhood (1-4 years) |
43 |
42 |
$3K |
| D9999 |
Unspecified adjunctive procedure, by report |
55 |
55 |
$1K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
231 |
224 |
$898.50 |
| 99403 |
|
12 |
12 |
$658.36 |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
16 |
15 |
$652.64 |
| D0999 |
Unspecified diagnostic procedure, by report |
13 |
13 |
$260.00 |
| 90715 |
|
60 |
58 |
$167.50 |
| 87804 |
Infectious agent antigen detection by immunoassay; Influenza, each type |
14 |
14 |
$143.64 |
| 90710 |
|
39 |
39 |
$0.00 |
| 90670 |
|
13 |
13 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
87 |
87 |
$0.00 |