| Code | Description | Claims | Beneficiaries | Total Paid |
| T1015 |
Clinic visit/encounter, all-inclusive |
31,820 |
21,050 |
$2.13M |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
8,261 |
3,880 |
$177K |
| D1351 |
Sealant - per tooth |
21,672 |
3,550 |
$113K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
1,885 |
948 |
$61K |
| D1120 |
Prophylaxis - child |
8,747 |
6,168 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
9,569 |
6,796 |
$42K |
| D1110 |
Prophylaxis - adult |
4,080 |
2,779 |
$38K |
| D1206 |
Topical application of fluoride varnish |
7,927 |
5,365 |
$36K |
| D1354 |
|
7,767 |
2,119 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,796 |
2,578 |
$26K |
| D0330 |
Panoramic radiographic image |
2,477 |
1,665 |
$26K |
| 99394 |
Periodic comprehensive preventive medicine reevaluation, established patient, adolescent (12-17 years) |
867 |
471 |
$25K |
| D0274 |
Bitewings - four radiographic images |
5,631 |
3,858 |
$21K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
2,743 |
1,319 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,610 |
3,896 |
$18K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
1,328 |
621 |
$18K |
| 90460 |
Immunization administration through 18 years of age via any route, first or only component |
1,655 |
963 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,653 |
4,279 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
7,281 |
4,926 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
680 |
361 |
$9K |
| D0272 |
Bitewings - two radiographic images |
3,876 |
2,917 |
$7K |
| 96160 |
|
2,747 |
1,494 |
$4K |
| D2140 |
|
941 |
464 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
821 |
584 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
59 |
13 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
543 |
344 |
$1K |
| 90686 |
|
492 |
264 |
$1K |
| 90734 |
|
476 |
267 |
$926.41 |
| 94010 |
|
34 |
18 |
$418.09 |
| 90651 |
|
162 |
95 |
$248.14 |
| 90658 |
|
316 |
174 |
$198.84 |
| 92551 |
|
41 |
26 |
$85.12 |
| 90715 |
|
113 |
58 |
$10.00 |
| G8510 |
Screening for depression is documented as negative, a follow-up plan is not required |
344 |
191 |
$5.76 |
| 3074F |
|
2,858 |
2,071 |
$0.00 |
| D0603 |
|
517 |
473 |
$0.00 |
| D1330 |
|
155 |
142 |
$0.00 |
| 3008F |
|
1,874 |
891 |
$0.00 |
| D2160 |
|
55 |
42 |
$0.00 |
| D2331 |
|
18 |
12 |
$0.00 |
| 3079F |
|
45 |
26 |
$0.00 |
| 90688 |
|
22 |
12 |
$0.00 |
| 3078F |
|
3,721 |
2,018 |
$0.00 |
| D0191 |
|
69 |
39 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
61 |
$0.00 |