| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 90460 |
Immunization administration through 18 years of age via any route, first or only component |
3,692 |
3,652 |
$162K |
| 90461 |
|
2,067 |
2,050 |
$129K |
| D1351 |
Sealant - per tooth |
907 |
877 |
$80K |
| D0191 |
|
3,862 |
3,637 |
$76K |
| D1206 |
Topical application of fluoride varnish |
4,367 |
4,134 |
$73K |
| D1120 |
Prophylaxis - child |
792 |
652 |
$36K |
| 87591 |
Infectious agent detection by nucleic acid; Neisseria gonorrhoeae, amplified probe |
560 |
544 |
$26K |
| 87491 |
Infectious agent detection by nucleic acid; Chlamydia trachomatis, amplified probe |
535 |
520 |
$25K |
| 90632 |
|
275 |
272 |
$16K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
278 |
270 |
$10K |
| 99202 |
Office or other outpatient visit for the evaluation and management of a new patient, straightforward |
189 |
175 |
$10K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
430 |
425 |
$9K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
72 |
68 |
$4K |
| 99203 |
Office or other outpatient visit for the evaluation and management of a new patient, low complexity |
28 |
28 |
$3K |
| 90633 |
|
1,448 |
1,431 |
$2K |
| 90670 |
|
1,342 |
1,327 |
$2K |
| 90651 |
|
320 |
317 |
$2K |
| 90686 |
|
740 |
733 |
$1K |
| 99201 |
|
37 |
37 |
$1K |
| 99385 |
|
14 |
13 |
$1K |
| 90698 |
|
1,015 |
1,003 |
$1K |
| 90688 |
|
87 |
87 |
$1K |
| 90744 |
|
719 |
709 |
$1K |
| 90681 |
|
558 |
552 |
$736.00 |
| 90734 |
|
294 |
292 |
$731.20 |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
35 |
35 |
$357.80 |
| 81025 |
|
171 |
164 |
$351.50 |
| 90700 |
|
196 |
189 |
$334.50 |
| 90716 |
|
202 |
199 |
$319.40 |
| 90707 |
|
235 |
231 |
$304.30 |
| 90648 |
|
217 |
211 |
$276.00 |
| 90620 |
|
63 |
63 |
$159.75 |
| 90710 |
|
106 |
105 |
$128.80 |
| 90715 |
|
102 |
101 |
$110.40 |
| 90696 |
|
59 |
59 |
$95.30 |
| A4267 |
Contraceptive supply, condom, male, each |
25 |
24 |
$69.25 |
| 90685 |
|
98 |
96 |
$55.20 |
| D1310 |
|
256 |
252 |
$0.00 |
| D0601 |
|
952 |
948 |
$0.00 |
| D1320 |
|
650 |
627 |
$0.00 |
| D0602 |
|
1,201 |
1,060 |
$0.00 |
| G0008 |
Administration of influenza virus vaccine |
18 |
18 |
$0.00 |
| D0603 |
|
247 |
240 |
$0.00 |
| D1330 |
|
2,111 |
1,939 |
$0.00 |