| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| S0302 |
Completed early periodic screening diagnosis and treatment (epsdt) service (list in addition to code for appropriate evaluation and management service) |
163 |
155 |
$7K |
| 90460 |
Immunization administration through 18 years of age via any route, first or only component |
121 |
118 |
$1K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
29 |
26 |
$776.55 |
| 96127 |
|
86 |
75 |
$242.49 |
| S0281 |
Medical home program, comprehensive care coordination and planning, maintenance of plan |
38 |
38 |
$236.10 |
| 96110 |
Developmental screening, with scoring and documentation, per standardized instrument |
81 |
75 |
$137.60 |
| 92551 |
|
41 |
40 |
$97.59 |
| 99188 |
|
27 |
27 |
$22.63 |
| 99173 |
|
41 |
40 |
$21.80 |
| X5622 |
|
160 |
153 |
$0.00 |
| 90686 |
|
65 |
64 |
$0.00 |
| S0280 |
Medical home program, comprehensive care coordination and planning, initial plan |
13 |
13 |
$0.00 |