| Code | Description | Claims | Beneficiaries | Total Paid |
| D1110 |
Prophylaxis - adult |
19,045 |
18,424 |
$969K |
| D0120 |
Periodic oral evaluation - established patient |
20,860 |
20,136 |
$550K |
| D1120 |
Prophylaxis - child |
13,903 |
13,429 |
$528K |
| D1206 |
Topical application of fluoride varnish |
23,280 |
22,415 |
$486K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,213 |
2,485 |
$411K |
| D0274 |
Bitewings - four radiographic images |
9,497 |
9,158 |
$303K |
| D1351 |
Sealant - per tooth |
9,702 |
2,034 |
$236K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,560 |
1,757 |
$228K |
| D0140 |
Limited oral evaluation - problem focused |
4,678 |
4,505 |
$186K |
| D0330 |
Panoramic radiographic image |
2,739 |
2,625 |
$170K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,392 |
641 |
$126K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,915 |
1,806 |
$83K |
| D4910 |
|
801 |
792 |
$55K |
| D0272 |
Bitewings - two radiographic images |
2,111 |
2,049 |
$51K |
| D0220 |
Intraoral - periapical first radiographic image |
2,567 |
2,435 |
$46K |
| D0210 |
Intraoral - complete series of radiographic images |
720 |
707 |
$46K |
| D1354 |
|
1,591 |
560 |
$29K |
| D9310 |
|
339 |
283 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
34 |
25 |
$6K |
| D2331 |
|
57 |
36 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
18 |
13 |
$3K |
| D1330 |
|
105 |
93 |
$3K |
| D9920 |
|
12 |
12 |
$624.00 |
| G0071 |
Payment for communication technology-based services for 5 minutes or more of a virtual (non-face-to-face) communication between an rural health clinic (rhc) or federally qualified health center (fqhc) practitioner and rhc or fqhc patient, or 5 minutes or more of remote evaluation of recorded video and/or images by an rhc or fqhc practitioner, occurring in lieu of an office visit; rhc or fqhc only |
27 |
26 |
$303.48 |
| D0603 |
|
16 |
13 |
$0.00 |