| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,726 |
2,719 |
$131K |
| D1110 |
Prophylaxis - adult |
1,848 |
1,839 |
$78K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
966 |
773 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
4,022 |
3,987 |
$50K |
| D0274 |
Bitewings - four radiographic images |
1,592 |
1,581 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
835 |
592 |
$28K |
| D0330 |
Panoramic radiographic image |
272 |
272 |
$19K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
732 |
549 |
$14K |
| D1206 |
Topical application of fluoride varnish |
4,811 |
4,795 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
277 |
277 |
$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 |
1,482 |
1,190 |
$11K |
| D1351 |
Sealant - per tooth |
380 |
133 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
415 |
406 |
$6K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
524 |
453 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
4,550 |
4,501 |
$4K |
| D1330 |
|
4,986 |
4,957 |
$3K |
| D0272 |
Bitewings - two radiographic images |
2,017 |
2,008 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
51 |
51 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,879 |
3,777 |
$3K |
| H0004 |
Behavioral health counseling and therapy, per 15 minutes |
16 |
13 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
98 |
98 |
$2K |
| D1999 |
|
14 |
14 |
$820.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$810.95 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
49 |
43 |
$618.33 |
| D0999 |
Unspecified diagnostic procedure, by report |
15 |
15 |
$300.00 |