| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,276 |
1,253 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,006 |
990 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
555 |
436 |
$30K |
| D1110 |
Prophylaxis - adult |
663 |
658 |
$27K |
| D1351 |
Sealant - per tooth |
1,187 |
373 |
$17K |
| D0274 |
Bitewings - four radiographic images |
787 |
771 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
1,213 |
1,183 |
$14K |
| 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 |
1,819 |
1,435 |
$12K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
1,126 |
940 |
$10K |
| D0330 |
Panoramic radiographic image |
202 |
193 |
$9K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
435 |
334 |
$8K |
| D1206 |
Topical application of fluoride varnish |
2,053 |
2,011 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
482 |
470 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
132 |
112 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
107 |
107 |
$3K |
| D0272 |
Bitewings - two radiographic images |
1,041 |
1,024 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
2,769 |
2,697 |
$2K |
| D1330 |
|
2,230 |
2,200 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,167 |
2,084 |
$1K |
| D9999 |
Unspecified adjunctive procedure, by report |
42 |
42 |
$1K |
| D3120 |
|
67 |
53 |
$227.36 |