| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
8,674 |
7,793 |
$422K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,881 |
1,399 |
$232K |
| D0120 |
Periodic oral evaluation - established patient |
8,658 |
7,806 |
$221K |
| D1206 |
Topical application of fluoride varnish |
8,776 |
7,879 |
$170K |
| D0274 |
Bitewings - four radiographic images |
4,033 |
3,589 |
$118K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,443 |
771 |
$108K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,354 |
2,023 |
$101K |
| D1120 |
Prophylaxis - child |
2,636 |
2,296 |
$88K |
| D0140 |
Limited oral evaluation - problem focused |
2,249 |
2,028 |
$87K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
906 |
615 |
$76K |
| D0330 |
Panoramic radiographic image |
1,065 |
917 |
$55K |
| D0220 |
Intraoral - periapical first radiographic image |
2,535 |
2,209 |
$41K |
| D0210 |
Intraoral - complete series of radiographic images |
605 |
521 |
$40K |
| 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 |
732 |
405 |
$9K |
| D2330 |
|
42 |
27 |
$3K |
| D0272 |
Bitewings - two radiographic images |
126 |
100 |
$2K |
| T1015 |
Clinic visit/encounter, all-inclusive |
68 |
52 |
$2K |
| D1351 |
Sealant - per tooth |
79 |
12 |
$2K |
| D1354 |
|
125 |
28 |
$2K |
| D4355 |
|
13 |
12 |
$2K |
| D1330 |
|
91 |
83 |
$387.00 |
| G2025 |
Payment for a telehealth distant site service furnished by a rural health clinic (rhc) or federally qualified health center (fqhc) only |
26 |
15 |
$184.10 |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
177 |
105 |
$0.00 |