| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
5,476 |
4,209 |
$866K |
| 3074F |
|
549 |
494 |
$405.00 |
| 3078F |
|
411 |
381 |
$385.00 |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
290 |
248 |
$145.54 |
| 3079F |
|
206 |
185 |
$125.00 |
| D1110 |
Prophylaxis - adult |
124 |
123 |
$82.00 |
| D0140 |
Limited oral evaluation - problem focused |
180 |
173 |
$70.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
12 |
$65.00 |
| 3075F |
|
27 |
26 |
$50.00 |
| D0330 |
Panoramic radiographic image |
112 |
112 |
$42.00 |
| D0220 |
Intraoral - periapical first radiographic image |
340 |
334 |
$39.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
192 |
183 |
$26.00 |
| 4004F |
|
162 |
146 |
$0.00 |
| 1159F |
|
764 |
678 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
113 |
112 |
$0.00 |
| 1034F |
|
158 |
137 |
$0.00 |
| 1126F |
|
353 |
323 |
$0.00 |
| 3008F |
|
760 |
677 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
185 |
185 |
$0.00 |
| 1125F |
|
52 |
47 |
$0.00 |
| 1036F |
|
572 |
473 |
$0.00 |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
301 |
274 |
$0.00 |
| G0467 |
Federally qualified health center (fqhc) visit, established patient; a medically-necessary, face-to-face encounter (one-on-one) between an established patient and a fqhc practitioner during which time one or more fqhc services are rendered and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving a fqhc visit |
50 |
39 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
51 |
51 |
$0.00 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
15 |
14 |
$0.00 |