| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,361 |
3,145 |
$135K |
| D1206 |
Topical application of fluoride varnish |
4,010 |
3,726 |
$134K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
607 |
160 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
3,435 |
3,305 |
$77K |
| D7140 |
Extraction, erupted tooth or exposed root |
665 |
326 |
$55K |
| D1351 |
Sealant - per tooth |
1,726 |
567 |
$54K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
519 |
372 |
$39K |
| D1110 |
Prophylaxis - adult |
602 |
568 |
$33K |
| D0330 |
Panoramic radiographic image |
528 |
522 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
310 |
256 |
$32K |
| T1015 |
Clinic visit/encounter, all-inclusive |
305 |
303 |
$30K |
| U0003 |
Infectious agent detection by nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, making use of high throughput technologies as described by cms-2020-01-r |
309 |
268 |
$28K |
| D0274 |
Bitewings - four radiographic images |
780 |
744 |
$25K |
| D0272 |
Bitewings - two radiographic images |
975 |
967 |
$22K |
| D9420 |
|
87 |
86 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
256 |
251 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
231 |
218 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
283 |
192 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
207 |
202 |
$3K |
| U0005 |
Infectious agent detection by nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, cdc or non-cdc, making use of high throughput technologies, completed within 2 calendar days from date of specimen collection (list separately in addition to either hcpcs code u0003 or u0004) as described by cms-2020-01-r2 |
30 |
30 |
$775.28 |
| D0240 |
|
25 |
25 |
$710.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$435.00 |