| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,577 |
2,574 |
$106K |
| D1110 |
Prophylaxis - adult |
4,945 |
4,919 |
$100K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,335 |
2,490 |
$95K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,471 |
2,035 |
$93K |
| D1206 |
Topical application of fluoride varnish |
7,508 |
7,483 |
$87K |
| D0210 |
Intraoral - complete series of radiographic images |
4,093 |
4,071 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,529 |
4,502 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
4,980 |
4,974 |
$51K |
| D9999 |
Unspecified adjunctive procedure, by report |
398 |
381 |
$44K |
| D0230 |
Intraoral - periapical each additional radiographic image |
20,825 |
4,472 |
$42K |
| D2740 |
Crown - porcelain/ceramic |
125 |
125 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
6,587 |
6,368 |
$32K |
| D0274 |
Bitewings - four radiographic images |
3,917 |
3,911 |
$32K |
| D9430 |
|
3,353 |
3,161 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
236 |
146 |
$8K |
| D4341 |
|
273 |
105 |
$6K |
| D0270 |
|
1,520 |
1,485 |
$3K |
| D0999 |
Unspecified diagnostic procedure, by report |
46 |
46 |
$3K |
| D1351 |
Sealant - per tooth |
50 |
15 |
$2K |
| D2331 |
|
39 |
30 |
$1K |
| G2025 |
Payment for a telehealth distant site service furnished by a rural health clinic (rhc) or federally qualified health center (fqhc) only |
15 |
14 |
$266.84 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$260.00 |
| D0603 |
|
847 |
844 |
$0.00 |
| D0601 |
|
569 |
562 |
$0.00 |
| D0602 |
|
122 |
122 |
$0.00 |