| Code | Description | Claims | Beneficiaries | Total Paid |
| T1015 |
Clinic visit/encounter, all-inclusive |
21,239 |
12,356 |
$1.14M |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
4,522 |
2,297 |
$98K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
5,954 |
2,829 |
$76K |
| 99394 |
Periodic comprehensive preventive medicine reevaluation, established patient, adolescent (12-17 years) |
1,682 |
907 |
$54K |
| D1351 |
Sealant - per tooth |
6,547 |
1,134 |
$42K |
| D1110 |
Prophylaxis - adult |
3,226 |
1,931 |
$29K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
199 |
140 |
$22K |
| D1206 |
Topical application of fluoride varnish |
5,529 |
3,468 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
3,907 |
2,233 |
$20K |
| 90460 |
Immunization administration through 18 years of age via any route, first or only component |
1,163 |
701 |
$17K |
| D0274 |
Bitewings - four radiographic images |
4,539 |
2,540 |
$17K |
| D1120 |
Prophylaxis - child |
3,227 |
2,029 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,620 |
2,074 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
910 |
468 |
$14K |
| D0330 |
Panoramic radiographic image |
2,724 |
1,515 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,248 |
3,171 |
$13K |
| 90651 |
|
266 |
170 |
$13K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
700 |
329 |
$11K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
1,472 |
757 |
$10K |
| 96160 |
|
7,010 |
3,660 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
5,831 |
3,438 |
$8K |
| D2140 |
|
859 |
381 |
$4K |
| 90734 |
|
144 |
93 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
289 |
158 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
60 |
44 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
96 |
54 |
$1K |
| D0272 |
Bitewings - two radiographic images |
1,437 |
785 |
$1K |
| 90688 |
|
257 |
140 |
$915.16 |
| 90621 |
|
15 |
12 |
$881.35 |
| 94010 |
|
81 |
43 |
$769.42 |
| D1354 |
|
880 |
177 |
$405.00 |
| 92551 |
|
86 |
48 |
$279.68 |
| 90733 |
|
29 |
18 |
$112.50 |
| 90686 |
|
167 |
98 |
$82.03 |
| 90658 |
|
30 |
17 |
$20.78 |
| 3078F |
|
4,173 |
2,386 |
$0.00 |
| 3008F |
|
1,767 |
912 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
222 |
140 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
37 |
$0.00 |
| 3074F |
|
2,862 |
2,310 |
$0.00 |
| 3079F |
|
295 |
189 |
$0.00 |
| D0603 |
|
178 |
164 |
$0.00 |
| 3075F |
|
78 |
70 |
$0.00 |