| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,700 |
1,690 |
$74K |
| D0330 |
Panoramic radiographic image |
725 |
723 |
$42K |
| D1110 |
Prophylaxis - adult |
873 |
871 |
$35K |
| D1351 |
Sealant - per tooth |
1,480 |
409 |
$27K |
| D0274 |
Bitewings - four radiographic images |
917 |
915 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
2,099 |
2,073 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
360 |
318 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
523 |
518 |
$12K |
| 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 |
1,276 |
1,015 |
$11K |
| H1000 |
Prenatal care, at-risk assessment |
62 |
52 |
$8K |
| D1206 |
Topical application of fluoride varnish |
2,969 |
2,958 |
$5K |
| 99381 |
|
38 |
38 |
$5K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
494 |
415 |
$3K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
267 |
213 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
136 |
135 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
32 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
3,421 |
3,376 |
$2K |
| D0272 |
Bitewings - two radiographic images |
1,292 |
1,286 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,937 |
2,820 |
$1K |
| D1330 |
|
2,960 |
2,944 |
$991.75 |
| D9999 |
Unspecified adjunctive procedure, by report |
12 |
12 |
$300.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
12 |
12 |
$240.00 |
| G0008 |
Administration of influenza virus vaccine |
18 |
14 |
$113.60 |