| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
2,601 |
1,420 |
$256K |
| D0999 |
Unspecified diagnostic procedure, by report |
2,949 |
2,131 |
$241K |
| D0120 |
Periodic oral evaluation - established patient |
682 |
566 |
$436.20 |
| D1120 |
Prophylaxis - child |
592 |
479 |
$410.00 |
| D1206 |
Topical application of fluoride varnish |
756 |
606 |
$378.85 |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
1,168 |
655 |
$56.70 |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
95 |
68 |
$27.83 |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$26.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
162 |
131 |
$21.05 |
| 90686 |
|
302 |
176 |
$12.80 |
| D0603 |
|
75 |
75 |
$0.00 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
612 |
352 |
$0.00 |
| D1330 |
|
330 |
177 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
52 |
37 |
$0.00 |
| 92551 |
|
69 |
43 |
$0.00 |
| D1351 |
Sealant - per tooth |
17 |
16 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
181 |
121 |
$0.00 |
| 96110 |
Developmental screening, with scoring and documentation, per standardized instrument |
82 |
56 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
93 |
90 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
153 |
104 |
$0.00 |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
13 |
13 |
$0.00 |
| 99173 |
|
58 |
32 |
$0.00 |
| 99392 |
Periodic comprehensive preventive medicine reevaluation, established patient, early childhood (1-4 years) |
37 |
13 |
$0.00 |