| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
146 |
117 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
184 |
145 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
159 |
123 |
$3K |
| 92014 |
Ophthalmological services: medical examination and evaluation, comprehensive, established patient |
12 |
12 |
$693.36 |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
768 |
664 |
$404.61 |
| 92015 |
Determination of refractive state |
17 |
17 |
$341.19 |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
61 |
53 |
$91.01 |
| 80053 |
Comprehensive metabolic panel |
49 |
40 |
$19.42 |
| 84443 |
Thyroid stimulating hormone (TSH) |
15 |
12 |
$5.95 |
| 83036 |
Hemoglobin; glycosylated (A1C) |
14 |
12 |
$5.49 |
| 36415 |
Collection of venous blood by venipuncture |
60 |
53 |
$2.25 |
| 3078F |
|
57 |
56 |
$0.00 |
| G8510 |
Screening for depression is documented as negative, a follow-up plan is not required |
47 |
39 |
$0.00 |
| 99309 |
Subsequent nursing facility care, per day, low to moderate complexity |
13 |
12 |
$0.00 |
| 36416 |
|
16 |
12 |
$0.00 |
| 3074F |
|
45 |
43 |
$0.00 |