MISSISSIPPI HEADWATERS AREA DENTAL HEALTH CENTER, INC.

$463K

Total Medicaid Paid

7,737

Total Claims

6,706

Beneficiaries

20

Codes Billed

2023-12

First Month

2024-12

Last Month

Authorized Official	LUNDBERG, ERICA (DIRECTOR OF FINANCE AND OPERATIONS)
Parent Organization	MISSISSIPPI HEADWATERS AREA DENTAL HEALTH CENTER
NPI Enumeration Date	08/15/2023

Provider	City	State	Total Paid
MISSISSIPPI HEADWATERS AREA DENTAL HEALTH CENTER, INC.	HALSTAD	MN	$1.08M
MISSISSIPPI HEADWATERS AREA DENTAL HEALTH CENTER, INC.	PARK RAPIDS	MN	$341K

Year	Claims	Total Paid
2023	561	$17K
2024	7,176	$446K

Code	Description	Claims	Beneficiaries	Total Paid
D0330	Panoramic radiographic image	894	825	$83K
D0150	Comprehensive oral evaluation - new or established patient	1,087	1,004	$59K
D2392	Resin-based composite - two surfaces, posterior, primary or permanent	416	304	$46K
D1110	Prophylaxis - adult	517	496	$38K
D7140	Extraction, erupted tooth or exposed root	296	144	$33K
D0274	Bitewings - four radiographic images	680	629	$33K
D1330		831	786	$30K
D1206	Topical application of fluoride varnish	800	755	$30K
D2391	Resin-based composite - one surface, posterior, primary or permanent	265	200	$24K
D1120	Prophylaxis - child	438	412	$22K
D0140	Limited oral evaluation - problem focused	244	225	$13K
D0120	Periodic oral evaluation - established patient	210	210	$12K
D1351	Sealant - per tooth	222	61	$10K
D2393	Resin-based composite - three surfaces, posterior, primary or permanent	63	56	$9K
D0272	Bitewings - two radiographic images	178	154	$7K
D0220	Intraoral - periapical first radiographic image	235	209	$4K
D9230	Inhalation of nitrous oxide / analgesia, anxiolysis	136	121	$3K
D1310		72	72	$2K
D2331		15	13	$2K
D0230	Intraoral - periapical each additional radiographic image	138	30	$593.60

Medicaid Provider Spending