| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,927 |
1,843 |
$91K |
| D0120 |
Periodic oral evaluation - established patient |
3,677 |
3,496 |
$81K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
4,320 |
3,822 |
$81K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
5,306 |
4,513 |
$65K |
| H1000 |
Prenatal care, at-risk assessment |
373 |
275 |
$62K |
| 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 |
6,882 |
5,899 |
$49K |
| D1351 |
Sealant - per tooth |
5,307 |
1,652 |
$49K |
| D1120 |
Prophylaxis - child |
1,722 |
1,644 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
517 |
380 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
794 |
766 |
$21K |
| D0274 |
Bitewings - four radiographic images |
2,243 |
2,135 |
$20K |
| D1354 |
|
4,475 |
882 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
1,822 |
1,786 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
445 |
312 |
$12K |
| D1206 |
Topical application of fluoride varnish |
5,411 |
5,228 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
375 |
300 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
173 |
110 |
$6K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
171 |
145 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
84 |
84 |
$4K |
| 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 |
503 |
485 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,107 |
3,874 |
$3K |
| D0190 |
|
83 |
83 |
$2K |
| D0330 |
Panoramic radiographic image |
541 |
496 |
$1K |
| D0272 |
Bitewings - two radiographic images |
1,658 |
1,574 |
$1K |
| G0008 |
Administration of influenza virus vaccine |
83 |
77 |
$1K |
| D0191 |
|
394 |
392 |
$825.55 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
29 |
25 |
$799.88 |
| D1330 |
|
4,060 |
3,881 |
$773.24 |
| D0220 |
Intraoral - periapical first radiographic image |
4,992 |
4,732 |
$642.81 |
| 99392 |
Periodic comprehensive preventive medicine reevaluation, established patient, early childhood (1-4 years) |
60 |
60 |
$600.00 |
| 99393 |
Periodic comprehensive preventive medicine reevaluation, established patient, late childhood (5-11 years) |
56 |
56 |
$560.00 |
| 90662 |
|
34 |
33 |
$504.56 |
| 99391 |
Periodic comprehensive preventive medicine reevaluation, established patient, infant (under 1 year) |
29 |
28 |
$290.00 |
| D0603 |
|
2,840 |
2,827 |
$190.00 |
| 92587 |
|
108 |
108 |
$46.89 |
| D0270 |
|
306 |
306 |
$35.96 |
| D0601 |
|
247 |
247 |
$20.00 |
| 87804 |
Infectious agent antigen detection by immunoassay; Influenza, each type |
156 |
78 |
$19.86 |
| 90670 |
|
21 |
21 |
$15.00 |
| 90686 |
|
57 |
57 |
$15.00 |
| 90723 |
|
13 |
13 |
$15.00 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
334 |
332 |
$10.00 |
| G0439 |
Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit |
297 |
280 |
$7.42 |
| 1160F |
|
98 |
81 |
$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 |
379 |
360 |
$0.00 |
| 81003 |
|
95 |
68 |
$0.00 |
| 90648 |
|
30 |
30 |
$0.00 |
| 3078F |
|
133 |
102 |
$0.00 |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
139 |
138 |
$0.00 |
| 76805 |
Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation |
13 |
12 |
$0.00 |
| Q0091 |
Screening papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory |
13 |
13 |
$0.00 |
| 3725F |
|
39 |
38 |
$0.00 |
| 81025 |
|
25 |
25 |
$0.00 |
| 87880 |
Infectious agent antigen detection by immunoassay; Streptococcus, group A |
48 |
47 |
$0.00 |
| D0240 |
|
32 |
32 |
$0.00 |
| 99000 |
|
88 |
86 |
$0.00 |
| 3008F |
|
263 |
218 |
$0.00 |
| 85018 |
|
13 |
13 |
$0.00 |
| D0602 |
|
284 |
283 |
$0.00 |
| 1036F |
|
225 |
181 |
$0.00 |
| 3074F |
|
143 |
110 |
$0.00 |
| 36415 |
Collection of venous blood by venipuncture |
130 |
121 |
$0.00 |
| 1126F |
|
76 |
65 |
$0.00 |