| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,720 |
972 |
$92K |
| 90460 |
Immunization administration through 18 years of age via any route, first or only component |
1,284 |
867 |
$18K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
1,865 |
1,496 |
$12K |
| 0071A |
|
120 |
117 |
$11K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
847 |
647 |
$8K |
| 0064A |
|
98 |
96 |
$8K |
| 0072A |
|
74 |
73 |
$7K |
| 92012 |
Ophthalmological services: medical examination and evaluation, intermediate, established patient |
221 |
202 |
$5K |
| 0004A |
|
39 |
37 |
$3K |
| 0001A |
|
26 |
25 |
$3K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
93 |
86 |
$2K |
| 90686 |
|
602 |
457 |
$2K |
| 90632 |
|
69 |
57 |
$2K |
| 99202 |
Office or other outpatient visit for the evaluation and management of a new patient, straightforward |
115 |
101 |
$1K |
| 0012A |
|
37 |
37 |
$1K |
| 86580 |
|
223 |
165 |
$953.53 |
| 90651 |
|
64 |
63 |
$799.86 |
| 81025 |
|
139 |
112 |
$779.12 |
| 0011A |
|
35 |
35 |
$773.44 |
| 0002A |
|
20 |
18 |
$700.74 |
| 99407 |
|
29 |
28 |
$628.14 |
| 99203 |
Office or other outpatient visit for the evaluation and management of a new patient, low complexity |
12 |
12 |
$594.94 |
| 90715 |
|
123 |
115 |
$496.06 |
| 90734 |
|
245 |
220 |
$238.20 |
| 90619 |
|
80 |
73 |
$158.60 |
| 87110 |
|
121 |
107 |
$6.25 |
| 90620 |
|
17 |
17 |
$0.11 |
| A4267 |
Contraceptive supply, condom, male, each |
32 |
29 |
$0.09 |
| 90633 |
|
52 |
39 |
$0.08 |
| 87040 |
|
143 |
122 |
$0.00 |