| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| J3490 |
Unclassified drugs |
884 |
701 |
$110.78 |
| 87491 |
Infectious agent detection by nucleic acid; Chlamydia trachomatis, amplified probe |
779 |
775 |
$31.17 |
| 87591 |
Infectious agent detection by nucleic acid; Neisseria gonorrhoeae, amplified probe |
795 |
778 |
$31.07 |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
974 |
921 |
$22.91 |
| A4267 |
Contraceptive supply, condom, male, each |
614 |
611 |
$14.99 |
| 76815 |
Ultrasound, pregnant uterus, real time with image documentation, limited |
13 |
12 |
$0.00 |
| 99202 |
Office or other outpatient visit for the evaluation and management of a new patient, straightforward |
64 |
64 |
$0.00 |
| 99000 |
|
112 |
108 |
$0.00 |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
41 |
40 |
$0.00 |
| 81025 |
|
586 |
578 |
$0.00 |
| 87806 |
|
15 |
15 |
$0.00 |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
103 |
99 |
$0.00 |
| 99201 |
|
13 |
13 |
$0.00 |