CUSTOM SMILES DENTISTRY, PLLC
NPI: 1528678497
· ANDOVER, MN 55304
· Dental Clinic/Center
· NPI assigned 08/05/2020
$335K
Total Medicaid Paid
Provider Details
| Authorized Official | VANG, PAO CHUA (DENTIST) |
| NPI Enumeration Date | 08/05/2020 |
Monthly Spending Trend
Yearly Breakdown
| Year | Claims | Total Paid |
|---|
| 2020 |
32 |
$712.88 |
| 2021 |
268 |
$5K |
| 2022 |
2,397 |
$79K |
| 2023 |
3,107 |
$101K |
| 2024 |
4,159 |
$149K |
Billing Codes
| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,360 |
1,359 |
$40K |
| D0330 |
Panoramic radiographic image |
443 |
443 |
$39K |
| D1110 |
Prophylaxis - adult |
659 |
659 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,463 |
830 |
$34K |
| D0274 |
Bitewings - four radiographic images |
752 |
752 |
$32K |
| D1351 |
Sealant - per tooth |
801 |
164 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
626 |
625 |
$28K |
| D1120 |
Prophylaxis - child |
604 |
603 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
567 |
567 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
972 |
962 |
$17K |
| D0180 |
|
159 |
159 |
$15K |
| D1330 |
|
429 |
428 |
$14K |
| D0240 |
|
116 |
58 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$473.37 |