| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| S5102 |
Day care services, adult; per diem |
319 |
301 |
$257K |
| D1110 |
Prophylaxis - adult |
1,010 |
943 |
$26K |
| D4346 |
|
384 |
362 |
$24K |
| D1206 |
Topical application of fluoride varnish |
992 |
926 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
84 |
75 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
171 |
156 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
150 |
146 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
28 |
$491.41 |
| D1208 |
Topical application of fluoride, excluding varnish |
41 |
41 |
$434.04 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$238.98 |
| D0602 |
|
26 |
26 |
$0.00 |
| D1330 |
|
279 |
256 |
$0.00 |