| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
748 |
748 |
$73K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
857 |
683 |
$59K |
| D1120 |
Prophylaxis - child |
1,230 |
1,228 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
917 |
915 |
$33K |
| D1110 |
Prophylaxis - adult |
721 |
720 |
$31K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,020 |
981 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
1,032 |
1,031 |
$16K |
| D1206 |
Topical application of fluoride varnish |
2,210 |
2,205 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
194 |
159 |
$6K |
| D1351 |
Sealant - per tooth |
1,607 |
531 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
151 |
115 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
16 |
12 |
$3K |
| D9999 |
Unspecified adjunctive procedure, by report |
156 |
156 |
$3K |
| D0274 |
Bitewings - four radiographic images |
697 |
697 |
$3K |
| D0272 |
Bitewings - two radiographic images |
1,209 |
1,206 |
$2K |
| D1999 |
|
36 |
36 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$2K |
| D9430 |
|
16 |
16 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
67 |
$952.00 |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
635 |
553 |
$857.44 |
| D0603 |
|
2,132 |
2,039 |
$257.00 |
| 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 |
1,266 |
1,033 |
$83.88 |
| D0220 |
Intraoral - periapical first radiographic image |
81 |
81 |
$70.00 |
| D0602 |
|
85 |
75 |
$49.00 |
| D0601 |
|
16 |
15 |
$14.00 |
| D1330 |
|
2,128 |
2,124 |
$0.00 |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
182 |
165 |
$0.00 |