| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
5,893 |
5,527 |
$479K |
| D1120 |
Prophylaxis - child |
8,188 |
7,669 |
$443K |
| D0191 |
|
8,112 |
7,699 |
$184K |
| D1206 |
Topical application of fluoride varnish |
9,663 |
9,097 |
$167K |
| 90460 |
Immunization administration through 18 years of age via any route, first or only component |
3,594 |
3,451 |
$156K |
| 90461 |
|
2,137 |
2,061 |
$128K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
2,362 |
2,153 |
$88K |
| 87491 |
Infectious agent detection by nucleic acid; Chlamydia trachomatis, amplified probe |
1,185 |
1,129 |
$56K |
| 87591 |
Infectious agent detection by nucleic acid; Neisseria gonorrhoeae, amplified probe |
1,175 |
1,122 |
$56K |
| D1110 |
Prophylaxis - adult |
959 |
941 |
$52K |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
992 |
969 |
$44K |
| D9996 |
|
1,136 |
1,016 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
1,132 |
1,011 |
$30K |
| 99202 |
Office or other outpatient visit for the evaluation and management of a new patient, straightforward |
509 |
469 |
$29K |
| 99395 |
Periodic comprehensive preventive medicine reevaluation, established patient, 18-39 years |
278 |
268 |
$24K |
| 99201 |
|
560 |
540 |
$21K |
| D1354 |
|
745 |
622 |
$20K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
146 |
136 |
$9K |
| 90651 |
|
610 |
595 |
$9K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
317 |
308 |
$7K |
| D1321 |
|
606 |
492 |
$6K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
310 |
269 |
$5K |
| 90632 |
|
92 |
92 |
$5K |
| 86803 |
|
196 |
183 |
$3K |
| 90670 |
|
726 |
714 |
$3K |
| 82962 |
|
846 |
810 |
$3K |
| 90734 |
|
454 |
447 |
$2K |
| 86780 |
|
280 |
260 |
$2K |
| 0124A |
|
91 |
56 |
$2K |
| 90686 |
|
271 |
266 |
$2K |
| 90633 |
|
1,054 |
1,031 |
$2K |
| 85018 |
|
968 |
922 |
$2K |
| 90715 |
|
345 |
332 |
$2K |
| 86580 |
|
239 |
198 |
$2K |
| 92551 |
|
143 |
131 |
$1K |
| 0064A |
|
61 |
45 |
$1K |
| 0012A |
|
35 |
34 |
$1K |
| 90647 |
|
479 |
466 |
$1K |
| 90723 |
|
455 |
445 |
$1K |
| 96372 |
Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular |
40 |
39 |
$859.18 |
| 81025 |
|
449 |
421 |
$711.71 |
| 90716 |
|
103 |
95 |
$668.82 |
| 0011A |
|
21 |
21 |
$640.00 |
| 0134A |
|
38 |
22 |
$640.00 |
| 0031A |
|
15 |
14 |
$520.00 |
| S4993 |
Contraceptive pills for birth control |
25 |
25 |
$352.64 |
| J0696 |
Injection, ceftriaxone sodium, per 250 mg |
24 |
24 |
$320.40 |
| 99173 |
|
146 |
134 |
$320.04 |
| 99441 |
|
29 |
29 |
$298.35 |
| 90710 |
|
110 |
107 |
$282.60 |
| 90707 |
|
90 |
82 |
$258.54 |
| 36416 |
|
266 |
245 |
$216.00 |
| 90680 |
|
118 |
117 |
$184.00 |
| Q0112 |
All potassium hydroxide (koh) preparations |
25 |
25 |
$149.00 |
| 90697 |
|
13 |
13 |
$132.77 |
| Q0111 |
Wet mounts, including preparations of vaginal, cervical or skin specimens |
25 |
25 |
$125.50 |
| 90696 |
|
77 |
73 |
$117.00 |
| 82120 |
|
12 |
12 |
$64.68 |
| 90700 |
|
21 |
21 |
$55.20 |
| 36415 |
Collection of venous blood by venipuncture |
31 |
26 |
$12.00 |
| D1999 |
|
56 |
52 |
$0.00 |
| 90685 |
|
14 |
14 |
$0.00 |
| D1330 |
|
2,209 |
2,086 |
$0.00 |
| D0603 |
|
2,093 |
1,977 |
$0.00 |
| D1310 |
|
2,194 |
2,073 |
$0.00 |
| D1320 |
|
561 |
542 |
$0.00 |
| D0602 |
|
35 |
35 |
$0.00 |
| D0601 |
|
13 |
13 |
$0.00 |