| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
2,784 |
2,756 |
$53K |
| 99401 |
|
1,063 |
930 |
$27K |
| 90460 |
Immunization administration through 18 years of age via any route, first or only component |
690 |
667 |
$22K |
| D0190 |
|
1,945 |
1,929 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
111 |
83 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
210 |
205 |
$6K |
| D0274 |
Bitewings - four radiographic images |
254 |
249 |
$5K |
| D1120 |
Prophylaxis - child |
146 |
145 |
$5K |
| D1110 |
Prophylaxis - adult |
92 |
90 |
$4K |
| D0330 |
Panoramic radiographic image |
111 |
107 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
25 |
$2K |
| 96372 |
Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular |
118 |
109 |
$2K |
| 81025 |
|
347 |
310 |
$2K |
| D0272 |
Bitewings - two radiographic images |
89 |
88 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
52 |
51 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
43 |
43 |
$1K |
| T2028 |
Specialized supply, not otherwise specified, waiver |
88 |
79 |
$879.67 |
| 0002A |
|
20 |
18 |
$694.44 |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
27 |
27 |
$500.11 |
| D1351 |
Sealant - per tooth |
56 |
13 |
$448.29 |
| 99071 |
|
102 |
92 |
$224.56 |
| 96110 |
Developmental screening, with scoring and documentation, per standardized instrument |
28 |
28 |
$176.88 |
| 36415 |
Collection of venous blood by venipuncture |
90 |
85 |
$168.81 |
| 90707 |
|
42 |
39 |
$128.06 |
| 90716 |
|
43 |
40 |
$115.17 |
| 90715 |
|
44 |
44 |
$112.83 |
| 92551 |
|
13 |
13 |
$97.75 |
| 90686 |
|
172 |
170 |
$65.00 |
| 90461 |
|
144 |
139 |
$0.00 |
| D1330 |
|
97 |
80 |
$0.00 |
| 90651 |
|
12 |
12 |
$0.00 |
| 90674 |
|
167 |
165 |
$0.00 |