| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
6,029 |
5,300 |
$837K |
| T1040 |
Medicaid certified community behavioral health clinic services, per diem |
4,927 |
2,156 |
$684K |
| D9450 |
|
19,202 |
12,655 |
$577K |
| D1110 |
Prophylaxis - adult |
7,696 |
5,414 |
$282K |
| 90834 |
Psychotherapy, 45 minutes with patient |
1,953 |
854 |
$170K |
| D0120 |
Periodic oral evaluation - established patient |
8,200 |
6,070 |
$143K |
| D0274 |
Bitewings - four radiographic images |
3,550 |
2,672 |
$99K |
| D1120 |
Prophylaxis - child |
1,934 |
1,868 |
$94K |
| 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 |
1,790 |
1,519 |
$56K |
| D1206 |
Topical application of fluoride varnish |
1,713 |
1,642 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
783 |
437 |
$41K |
| D0210 |
Intraoral - complete series of radiographic images |
994 |
601 |
$40K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
645 |
361 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,216 |
1,187 |
$33K |
| D0140 |
Limited oral evaluation - problem focused |
975 |
591 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
344 |
212 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
535 |
367 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,820 |
1,184 |
$17K |
| D2140 |
|
279 |
159 |
$14K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
2,324 |
2,171 |
$13K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
2,099 |
1,919 |
$8K |
| D2331 |
|
77 |
36 |
$4K |
| D1351 |
Sealant - per tooth |
98 |
37 |
$4K |
| D0272 |
Bitewings - two radiographic images |
93 |
93 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
60 |
27 |
$3K |
| D9110 |
|
80 |
53 |
$2K |
| D2160 |
|
26 |
12 |
$1K |
| D2330 |
|
34 |
17 |
$1K |
| 99396 |
Periodic comprehensive preventive medicine reevaluation, established patient, 40-64 years |
25 |
25 |
$1K |
| 87426 |
Infectious agent antigen detection, SARS-CoV-2 (COVID-19) |
32 |
31 |
$1K |
| 90756 |
|
55 |
55 |
$486.79 |
| G2025 |
Payment for a telehealth distant site service furnished by a rural health clinic (rhc) or federally qualified health center (fqhc) only |
34 |
27 |
$448.31 |
| 90686 |
|
35 |
35 |
$396.33 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
273 |
271 |
$182.30 |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
17 |
16 |
$177.85 |
| 96110 |
Developmental screening, with scoring and documentation, per standardized instrument |
26 |
26 |
$68.11 |
| 94760 |
|
650 |
619 |
$0.00 |
| D9995 |
|
104 |
52 |
$0.00 |
| 0011A |
|
78 |
78 |
$0.00 |
| 0031A |
|
14 |
14 |
$0.00 |
| 0012A |
|
57 |
57 |
$0.00 |
| D1999 |
|
2,024 |
1,200 |
$0.00 |