| Code | Description | Claims | Beneficiaries | Total Paid |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
1,044 |
731 |
$285K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,159 |
4,140 |
$274K |
| D8670 |
Periodic orthodontic treatment visit |
836 |
830 |
$246K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,044 |
1,509 |
$203K |
| D0120 |
Periodic oral evaluation - established patient |
2,299 |
2,289 |
$186K |
| D1120 |
Prophylaxis - child |
3,095 |
3,085 |
$150K |
| D1110 |
Prophylaxis - adult |
1,362 |
1,352 |
$122K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
211 |
148 |
$100K |
| D9222 |
|
729 |
729 |
$88K |
| D0274 |
Bitewings - four radiographic images |
3,204 |
3,192 |
$68K |
| D0210 |
Intraoral - complete series of radiographic images |
1,246 |
1,242 |
$59K |
| D7240 |
Removal of impacted tooth - completely bony |
220 |
83 |
$51K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,300 |
6,151 |
$50K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
554 |
318 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,932 |
2,922 |
$39K |
| D9430 |
|
1,007 |
963 |
$32K |
| D7230 |
|
157 |
76 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
760 |
760 |
$27K |
| D4341 |
|
337 |
104 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
412 |
258 |
$22K |
| D4910 |
|
236 |
236 |
$18K |
| D2954 |
|
159 |
106 |
$17K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
93 |
40 |
$11K |
| D0350 |
|
1,207 |
476 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
762 |
745 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
66 |
26 |
$4K |
| D2394 |
|
31 |
14 |
$3K |
| D0272 |
Bitewings - two radiographic images |
173 |
173 |
$2K |