| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
1,859 |
1,738 |
$223K |
| 99403 |
|
1,348 |
1,304 |
$172K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
5,063 |
4,936 |
$15K |
| 90473 |
|
1,847 |
1,781 |
$10K |
| 99383 |
|
74 |
74 |
$9K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
2,064 |
2,005 |
$9K |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
604 |
590 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
89 |
88 |
$8K |
| 90686 |
|
2,004 |
1,998 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
170 |
167 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
28 |
$3K |
| 90715 |
|
646 |
638 |
$3K |
| 99384 |
|
16 |
16 |
$2K |
| 90723 |
|
141 |
141 |
$2K |
| 99382 |
|
14 |
14 |
$2K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
15 |
14 |
$1K |
| 90670 |
|
552 |
540 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
281 |
111 |
$854.78 |
| 90648 |
|
219 |
217 |
$797.50 |
| D1330 |
|
164 |
164 |
$787.31 |
| 90672 |
|
1,533 |
1,495 |
$585.75 |
| D1110 |
Prophylaxis - adult |
50 |
49 |
$572.60 |
| 90633 |
|
195 |
193 |
$528.00 |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
30 |
$336.00 |
| 90696 |
|
68 |
66 |
$324.50 |
| D1206 |
Topical application of fluoride varnish |
76 |
75 |
$312.30 |
| 90700 |
|
29 |
29 |
$258.50 |
| D1351 |
Sealant - per tooth |
62 |
15 |
$246.72 |
| 90651 |
|
336 |
332 |
$154.00 |
| 90734 |
|
227 |
225 |
$60.50 |
| 90707 |
|
57 |
57 |
$55.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$49.00 |
| D0191 |
|
16 |
16 |
$29.12 |
| 90716 |
|
42 |
42 |
$16.50 |
| 90710 |
|
224 |
217 |
$11.00 |
| D0274 |
Bitewings - four radiographic images |
18 |
17 |
$0.00 |
| 90660 |
|
369 |
341 |
$0.00 |
| 90656 |
|
94 |
94 |
$0.00 |
| 90697 |
|
13 |
13 |
$0.00 |
| 90674 |
|
17 |
13 |
$0.00 |
| 90619 |
|
47 |
47 |
$0.00 |