| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1017 |
Targeted case management, each 15 minutes |
1,896 |
1,273 |
$472K |
| D0191 |
|
4,517 |
4,508 |
$84K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
2,804 |
2,667 |
$50K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
611 |
583 |
$36K |
| S9470 |
Nutritional counseling, dietitian visit |
1,281 |
1,277 |
$33K |
| D1351 |
Sealant - per tooth |
1,623 |
367 |
$29K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
162 |
147 |
$14K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
809 |
565 |
$13K |
| D1120 |
Prophylaxis - child |
65 |
65 |
$5K |
| D1206 |
Topical application of fluoride varnish |
4,898 |
4,889 |
$5K |
| D0603 |
|
195 |
195 |
$2K |
| 99203 |
Office or other outpatient visit for the evaluation and management of a new patient, low complexity |
12 |
12 |
$871.92 |
| 36415 |
Collection of venous blood by venipuncture |
221 |
213 |
$504.27 |
| 90713 |
|
12 |
12 |
$318.24 |
| 90686 |
|
734 |
730 |
$238.22 |
| 90651 |
|
80 |
79 |
$211.83 |
| 87210 |
|
34 |
32 |
$172.92 |
| 81025 |
|
14 |
13 |
$108.50 |
| 90688 |
|
473 |
472 |
$67.11 |
| 90715 |
|
65 |
65 |
$55.72 |
| 90734 |
|
93 |
92 |
$0.48 |
| 90661 |
|
16 |
16 |
$0.00 |
| 90633 |
|
28 |
28 |
$0.00 |
| 90756 |
|
178 |
177 |
$0.00 |
| 87491 |
Infectious agent detection by nucleic acid; Chlamydia trachomatis, amplified probe |
23 |
13 |
$0.00 |
| 90710 |
|
42 |
42 |
$0.00 |
| 86703 |
|
12 |
12 |
$0.00 |
| 90620 |
|
29 |
28 |
$0.00 |
| 90674 |
|
79 |
79 |
$0.00 |
| 87591 |
Infectious agent detection by nucleic acid; Neisseria gonorrhoeae, amplified probe |
24 |
13 |
$0.00 |