| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
114 |
92 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
282 |
250 |
$17K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
277 |
257 |
$7K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
169 |
164 |
$6K |
| 99396 |
Periodic comprehensive preventive medicine reevaluation, established patient, 40-64 years |
13 |
13 |
$537.20 |
| 99395 |
Periodic comprehensive preventive medicine reevaluation, established patient, 18-39 years |
12 |
12 |
$487.79 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
25 |
25 |
$338.70 |
| 90460 |
Immunization administration through 18 years of age via any route, first or only component |
13 |
13 |
$207.70 |
| 36415 |
Collection of venous blood by venipuncture |
34 |
34 |
$99.17 |
| D0220 |
Intraoral - periapical first radiographic image |
368 |
358 |
$19.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
160 |
156 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
69 |
$0.00 |
| D0602 |
|
34 |
34 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
170 |
164 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
34 |
34 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
51 |
51 |
$0.00 |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$0.00 |
| D1120 |
Prophylaxis - child |
67 |
67 |
$0.00 |