| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
823 |
748 |
$44K |
| D0191 |
|
1,171 |
1,071 |
$25K |
| D1206 |
Topical application of fluoride varnish |
1,403 |
1,305 |
$24K |
| D1351 |
Sealant - per tooth |
196 |
185 |
$13K |
| 90460 |
Immunization administration through 18 years of age via any route, first or only component |
208 |
197 |
$11K |
| 87491 |
Infectious agent detection by nucleic acid; Chlamydia trachomatis, amplified probe |
153 |
145 |
$7K |
| 87591 |
Infectious agent detection by nucleic acid; Neisseria gonorrhoeae, amplified probe |
140 |
132 |
$7K |
| 90461 |
|
82 |
81 |
$5K |
| 97802 |
|
94 |
89 |
$5K |
| 90632 |
|
92 |
82 |
$5K |
| 99348 |
|
79 |
39 |
$3K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
119 |
106 |
$2K |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
30 |
26 |
$1K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
15 |
14 |
$954.42 |
| 81025 |
|
151 |
134 |
$228.12 |
| A4267 |
Contraceptive supply, condom, male, each |
155 |
143 |
$213.50 |
| 90670 |
|
13 |
12 |
$55.20 |