| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
1,588 |
1,311 |
$88K |
| D0330 |
Panoramic radiographic image |
323 |
188 |
$5K |
| 92004 |
Ophthalmological services: medical examination and evaluation, comprehensive, new patient |
290 |
228 |
$4K |
| 92015 |
Determination of refractive state |
715 |
567 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
289 |
159 |
$4K |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
134 |
97 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
190 |
101 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
389 |
223 |
$740.00 |
| D1206 |
Topical application of fluoride varnish |
75 |
45 |
$645.00 |
| 99203 |
Office or other outpatient visit for the evaluation and management of a new patient, low complexity |
21 |
12 |
$635.36 |
| 90460 |
Immunization administration through 18 years of age via any route, first or only component |
70 |
16 |
$605.25 |
| D1120 |
Prophylaxis - child |
40 |
27 |
$540.00 |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
24 |
12 |
$479.71 |
| D0274 |
Bitewings - four radiographic images |
64 |
41 |
$460.00 |
| D0210 |
Intraoral - complete series of radiographic images |
53 |
14 |
$383.40 |
| 92340 |
Fitting of spectacles, except for aphakia; monofocal |
17 |
13 |
$172.01 |
| D0230 |
Intraoral - periapical each additional radiographic image |
46 |
18 |
$100.00 |
| 92551 |
|
23 |
13 |
$80.24 |
| 99173 |
|
23 |
13 |
$31.68 |
| 4004F |
|
22 |
13 |
$0.00 |