| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,122 |
1,979 |
$115K |
| D0191 |
|
2,701 |
2,528 |
$59K |
| D1206 |
Topical application of fluoride varnish |
2,977 |
2,810 |
$52K |
| D1351 |
Sealant - per tooth |
455 |
434 |
$29K |
| 90460 |
Immunization administration through 18 years of age via any route, first or only component |
171 |
163 |
$8K |
| 87591 |
Infectious agent detection by nucleic acid; Neisseria gonorrhoeae, amplified probe |
89 |
79 |
$4K |
| 87491 |
Infectious agent detection by nucleic acid; Chlamydia trachomatis, amplified probe |
75 |
67 |
$3K |
| 90461 |
|
42 |
38 |
$2K |
| 97802 |
|
32 |
29 |
$2K |
| 90480 |
|
30 |
30 |
$1K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
25 |
24 |
$960.05 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
39 |
35 |
$598.11 |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
12 |
12 |
$565.44 |
| 90632 |
|
13 |
13 |
$429.19 |
| 90713 |
|
16 |
16 |
$350.00 |
| 86803 |
|
13 |
13 |
$252.46 |
| 90715 |
|
13 |
13 |
$249.48 |
| 86780 |
|
27 |
26 |
$225.71 |
| A4267 |
Contraceptive supply, condom, male, each |
158 |
126 |
$206.00 |
| 90633 |
|
24 |
24 |
$92.00 |
| 90656 |
|
23 |
23 |
$44.70 |
| 81025 |
|
28 |
24 |
$41.28 |
| 91322 |
|
13 |
13 |
$0.00 |