| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
16,531 |
16,018 |
$638K |
| D1351 |
Sealant - per tooth |
12,674 |
5,941 |
$632K |
| D0120 |
Periodic oral evaluation - established patient |
16,563 |
16,094 |
$441K |
| D1206 |
Topical application of fluoride varnish |
16,444 |
15,940 |
$389K |
| D0601 |
|
9,902 |
9,610 |
$30K |
| D0602 |
|
4,102 |
3,973 |
$13K |
| D0603 |
|
1,882 |
1,811 |
$7K |
| D0274 |
Bitewings - four radiographic images |
293 |
288 |
$5K |
| D0272 |
Bitewings - two radiographic images |
191 |
190 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
33 |
33 |
$832.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
156 |
150 |
$721.75 |