| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
840 |
834 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
511 |
350 |
$30K |
| 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 |
2,776 |
2,301 |
$26K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
1,438 |
1,249 |
$20K |
| D1110 |
Prophylaxis - adult |
513 |
510 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
585 |
348 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
1,214 |
1,205 |
$16K |
| D0330 |
Panoramic radiographic image |
294 |
292 |
$14K |
| D0274 |
Bitewings - four radiographic images |
559 |
553 |
$10K |
| D1351 |
Sealant - per tooth |
767 |
188 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
381 |
379 |
$7K |
| D1206 |
Topical application of fluoride varnish |
1,769 |
1,752 |
$7K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
614 |
499 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,331 |
1,748 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
284 |
282 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
2,108 |
2,076 |
$2K |
| D0272 |
Bitewings - two radiographic images |
750 |
745 |
$2K |
| D1330 |
|
1,755 |
1,744 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
37 |
37 |
$925.00 |
| 99381 |
|
13 |
13 |
$617.32 |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
14 |
$574.66 |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
14 |
13 |
$0.00 |