| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,670 |
1,741 |
$131K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
1,346 |
889 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
1,650 |
1,471 |
$56K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
589 |
413 |
$37K |
| D1120 |
Prophylaxis - child |
700 |
417 |
$25K |
| D0274 |
Bitewings - four radiographic images |
553 |
231 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
157 |
84 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
347 |
236 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
246 |
227 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
181 |
101 |
$9K |
| D0330 |
Panoramic radiographic image |
185 |
85 |
$6K |
| 99395 |
Periodic comprehensive preventive medicine reevaluation, established patient, 18-39 years |
120 |
38 |
$3K |
| 99215 |
Prolong outpt/office vis |
64 |
39 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
176 |
176 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
27 |
$2K |
| D0272 |
Bitewings - two radiographic images |
75 |
49 |
$1K |
| D1206 |
Topical application of fluoride varnish |
35 |
35 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
14 |
$1K |
| 99396 |
Periodic comprehensive preventive medicine reevaluation, established patient, 40-64 years |
12 |
12 |
$950.64 |
| 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 |
60 |
26 |
$905.43 |