| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
209 |
209 |
$10K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
207 |
193 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
116 |
116 |
$3K |
| D0330 |
Panoramic radiographic image |
97 |
97 |
$3K |
| D0274 |
Bitewings - four radiographic images |
110 |
110 |
$3K |
| D1120 |
Prophylaxis - child |
62 |
62 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
52 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
77 |
77 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
55 |
$770.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$665.00 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$234.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$208.00 |
| D1330 |
|
334 |
334 |
$0.00 |
| 1036F |
|
40 |
40 |
$0.00 |
| D1310 |
|
107 |
107 |
$0.00 |
| G8510 |
Screening for depression is documented as negative, a follow-up plan is not required |
239 |
223 |
$0.00 |
| 4004F |
|
115 |
107 |
$0.00 |
| G8431 |
Screening for depression is documented as being positive and a follow-up plan is documented |
13 |
13 |
$0.00 |