| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
1,896 |
1,684 |
$137K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
720 |
500 |
$14K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
565 |
308 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
179 |
129 |
$10K |
| D0330 |
Panoramic radiographic image |
240 |
158 |
$4K |
| D1110 |
Prophylaxis - adult |
193 |
119 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
105 |
73 |
$2K |
| D1120 |
Prophylaxis - child |
133 |
88 |
$2K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
145 |
65 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
180 |
114 |
$2K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
23 |
12 |
$733.48 |
| D0140 |
Limited oral evaluation - problem focused |
39 |
25 |
$571.65 |
| D0274 |
Bitewings - four radiographic images |
36 |
27 |
$554.30 |
| V2020 |
Frames, purchases |
27 |
27 |
$270.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$246.58 |
| 92015 |
Determination of refractive state |
15 |
15 |
$180.00 |
| 3078F |
|
137 |
129 |
$0.00 |
| 1159F |
|
377 |
348 |
$0.00 |
| 3074F |
|
258 |
236 |
$0.00 |
| 3079F |
|
40 |
38 |
$0.00 |