| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,586 |
1,584 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,397 |
1,115 |
$56K |
| D0330 |
Panoramic radiographic image |
751 |
748 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,966 |
1,961 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
763 |
762 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,677 |
1,672 |
$21K |
| D1120 |
Prophylaxis - child |
869 |
869 |
$20K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
6,288 |
5,273 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
684 |
535 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
516 |
269 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
198 |
167 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
1,221 |
1,217 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
1,755 |
1,751 |
$11K |
| 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 |
9,110 |
7,297 |
$10K |
| D1206 |
Topical application of fluoride varnish |
2,542 |
2,539 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,511 |
637 |
$6K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
2,635 |
2,199 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
1,990 |
1,971 |
$3K |
| D1999 |
|
44 |
44 |
$3K |
| D1351 |
Sealant - per tooth |
332 |
110 |
$2K |
| G0511 |
Rural health clinic or federally qualified health center (rhc or fqhc) only, general care management, 20 minutes or more of clinical staff time for chronic care management services or behavioral health integration services directed by an rhc or fqhc practitioner (physician, np, pa, or cnm), per calendar month |
159 |
126 |
$1K |
| D0272 |
Bitewings - two radiographic images |
414 |
414 |
$1K |
| D9999 |
Unspecified adjunctive procedure, by report |
90 |
90 |
$1K |
| D9430 |
|
13 |
13 |
$485.00 |
| D1330 |
|
2,589 |
2,585 |
$422.10 |
| 36415 |
Collection of venous blood by venipuncture |
454 |
390 |
$353.83 |
| D2331 |
|
17 |
13 |
$325.04 |
| D0603 |
|
3,272 |
3,213 |
$222.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
87 |
86 |
$164.00 |
| G0008 |
Administration of influenza virus vaccine |
119 |
91 |
$97.77 |
| 90662 |
|
14 |
12 |
$97.77 |
| D0602 |
|
128 |
122 |
$39.00 |
| D0601 |
|
33 |
30 |
$18.00 |
| G0439 |
Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit |
31 |
28 |
$0.00 |
| 90686 |
|
28 |
18 |
$0.00 |
| G0438 |
Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit |
82 |
79 |
$0.00 |
| G0468 |
Federally qualified health center (fqhc) visit, ippe or awv; a fqhc visit that includes an initial preventive physical examination (ippe) or annual wellness visit (awv) and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving an ippe or awv |
195 |
174 |
$0.00 |