| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| J7307 |
Etonogestrel implant system |
286 |
281 |
$233K |
| S4993 |
Contraceptive pills for bc |
1,039 |
1,034 |
$205K |
| 87491 |
|
2,451 |
2,440 |
$106K |
| 87591 |
|
2,451 |
2,440 |
$105K |
| J7304 |
Contraceptive hormone patch |
84 |
83 |
$96K |
| 99213 |
|
2,222 |
2,086 |
$81K |
| 99214 |
|
918 |
880 |
$63K |
| J1050 |
Medroxyprogesterone acetate |
734 |
733 |
$55K |
| 99212 |
|
1,398 |
1,321 |
$41K |
| S0199 |
Med abortion inc all ex drug |
53 |
53 |
$30K |
| J3490 |
Drugs unclassified injection |
1,109 |
1,075 |
$26K |
| Q3014 |
Telehealth facility fee |
1,207 |
1,151 |
$24K |
| A4267 |
Male condom |
1,674 |
1,625 |
$19K |
| 11981 |
|
104 |
95 |
$19K |
| 87806 |
|
682 |
675 |
$16K |
| 11976 |
|
213 |
103 |
$12K |
| 81025 |
|
2,744 |
2,619 |
$8K |
| 58300 |
|
82 |
40 |
$8K |
| 90674 |
|
203 |
199 |
$6K |
| 99203 |
|
44 |
44 |
$5K |
| J7303 |
Contraceptive vaginal ring |
33 |
25 |
$5K |
| 99204 |
|
36 |
35 |
$4K |
| 57454 |
|
66 |
31 |
$4K |
| 99395 |
|
43 |
43 |
$4K |
| 99202 |
|
50 |
49 |
$3K |
| Q0144 |
Azithromycin dihydrate, oral |
464 |
448 |
$2K |
| 99211 |
|
111 |
111 |
$2K |
| 96156 |
|
28 |
28 |
$2K |
| Q0111 |
Wet mounts/ w preparations |
344 |
341 |
$1K |
| 99000 |
|
621 |
603 |
$1K |
| 83986 |
|
343 |
340 |
$1K |
| J0696 |
Ceftriaxone sodium injection |
213 |
203 |
$1K |
| 58301 |
|
28 |
13 |
$734.79 |
| 81002 |
|
274 |
268 |
$639.31 |
| 90471 |
|
273 |
267 |
$490.60 |
| S5000 |
Prescription drug, generic |
624 |
495 |
$0.00 |
| S5001 |
Prescription drug,brand name |
40 |
40 |
$0.00 |
| 1159F |
|
14 |
14 |
$0.00 |
| 1160F |
|
14 |
14 |
$0.00 |