| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 90460 |
Immunization administration through 18 years of age via any route, first or only component |
961 |
954 |
$38K |
| 90461 |
|
179 |
177 |
$11K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
176 |
165 |
$10K |
| D1351 |
Sealant - per tooth |
103 |
103 |
$10K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
319 |
303 |
$8K |
| D1120 |
Prophylaxis - child |
141 |
141 |
$8K |
| 0012A |
|
307 |
302 |
$7K |
| D1206 |
Topical application of fluoride varnish |
364 |
342 |
$6K |
| 0011A |
|
320 |
314 |
$5K |
| D0191 |
|
162 |
162 |
$4K |
| 0001A |
|
104 |
103 |
$4K |
| 0002A |
|
73 |
73 |
$3K |
| 0013A |
|
78 |
78 |
$2K |
| 0064A |
|
73 |
60 |
$2K |
| 92551 |
|
81 |
80 |
$836.80 |
| 90632 |
|
13 |
13 |
$795.44 |
| 90633 |
|
307 |
307 |
$762.55 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
25 |
25 |
$565.25 |
| 0134A |
|
18 |
15 |
$480.00 |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
13 |
13 |
$424.08 |
| 90651 |
|
56 |
56 |
$377.80 |
| 99173 |
|
112 |
111 |
$259.56 |
| 96110 |
Developmental screening, with scoring and documentation, per standardized instrument |
14 |
14 |
$176.68 |
| 90734 |
|
79 |
79 |
$118.80 |
| A4267 |
Contraceptive supply, condom, male, each |
32 |
31 |
$77.50 |
| 90688 |
|
13 |
13 |
$59.36 |
| 81025 |
|
13 |
13 |
$22.36 |
| 91301 |
|
420 |
395 |
$0.00 |
| 0003A |
|
33 |
33 |
$0.00 |
| 90715 |
|
19 |
19 |
$0.00 |