| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
864 |
580 |
$55K |
| D1120 |
Prophylaxis - child |
847 |
840 |
$40K |
| D1110 |
Prophylaxis - adult |
1,011 |
1,002 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
993 |
603 |
$33K |
| D0330 |
Panoramic radiographic image |
439 |
436 |
$21K |
| 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 |
2,287 |
1,903 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
1,758 |
1,732 |
$16K |
| D0274 |
Bitewings - four radiographic images |
771 |
762 |
$15K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
1,233 |
1,086 |
$13K |
| D1351 |
Sealant - per tooth |
1,041 |
306 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
540 |
537 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,832 |
1,255 |
$8K |
| D1206 |
Topical application of fluoride varnish |
1,969 |
1,951 |
$6K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
473 |
395 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
142 |
138 |
$2K |
| D1330 |
|
2,283 |
2,265 |
$2K |
| D0272 |
Bitewings - two radiographic images |
645 |
637 |
$898.86 |
| D0220 |
Intraoral - periapical first radiographic image |
1,583 |
1,554 |
$783.22 |
| G0008 |
Administration of influenza virus vaccine |
15 |
15 |
$170.40 |
| 90674 |
|
15 |
15 |
$170.40 |