| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| H1010 |
Non-medical family planning education, per session |
2,289 |
1,857 |
$149K |
| S4993 |
Contraceptive pills for birth control |
2,330 |
1,495 |
$143K |
| D1351 |
Sealant - per tooth |
2,018 |
454 |
$34K |
| T1017 |
Targeted case management, each 15 minutes |
551 |
501 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,627 |
1,573 |
$20K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
492 |
442 |
$5K |
| A4267 |
Contraceptive supply, condom, male, each |
424 |
251 |
$4K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
319 |
262 |
$4K |
| 0012A |
|
73 |
57 |
$2K |
| 0011A |
|
77 |
60 |
$1K |
| 3008F |
|
155 |
131 |
$1K |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
291 |
268 |
$1K |
| 99000 |
|
467 |
341 |
$1K |
| A4268 |
Contraceptive supply, condom, female, each |
309 |
176 |
$959.76 |
| 0064A |
|
33 |
29 |
$915.84 |
| 99393 |
Periodic comprehensive preventive medicine reevaluation, established patient, late childhood (5-11 years) |
24 |
12 |
$616.13 |
| 0001A |
|
16 |
16 |
$572.40 |
| 0002A |
|
14 |
14 |
$496.08 |
| 90688 |
|
92 |
87 |
$485.25 |
| T1016 |
Case management, each 15 minutes |
31 |
13 |
$337.76 |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
14 |
13 |
$334.19 |
| 90686 |
|
115 |
111 |
$321.07 |
| 96372 |
Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular |
39 |
37 |
$121.36 |
| 36416 |
|
65 |
40 |
$115.17 |
| A4269 |
Contraceptive supply, spermicide (e.g., foam, gel), each |
13 |
13 |
$52.00 |
| 90685 |
|
101 |
101 |
$39.72 |
| 91300 |
|
40 |
33 |
$0.00 |
| 91307 |
|
12 |
12 |
$0.00 |
| 91301 |
|
199 |
147 |
$0.00 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
57 |
45 |
$0.00 |