| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
3,854 |
3,139 |
$251K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
2,323 |
1,166 |
$49K |
| D0330 |
Panoramic radiographic image |
1,268 |
952 |
$38K |
| D1110 |
Prophylaxis - adult |
1,207 |
970 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,357 |
1,033 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
1,551 |
1,276 |
$21K |
| D1206 |
Topical application of fluoride varnish |
1,855 |
1,449 |
$20K |
| D1120 |
Prophylaxis - child |
1,427 |
1,108 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
431 |
220 |
$17K |
| D0274 |
Bitewings - four radiographic images |
586 |
474 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
736 |
581 |
$2K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
216 |
113 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
86 |
42 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
24 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
92 |
67 |
$1K |
| 99203 |
Office or other outpatient visit for the evaluation and management of a new patient, low complexity |
40 |
18 |
$924.16 |
| 90460 |
Immunization administration through 18 years of age via any route, first or only component |
51 |
26 |
$645.00 |
| D0272 |
Bitewings - two radiographic images |
128 |
102 |
$520.00 |
| 87880 |
Infectious agent antigen detection by immunoassay; Streptococcus, group A |
31 |
14 |
$186.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
130 |
39 |
$185.00 |
| D1330 |
|
27 |
27 |
$0.00 |
| 1036F |
|
50 |
44 |
$0.00 |