| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| S4993 |
Contraceptive pills for birth control |
131 |
95 |
$13K |
| A4267 |
Contraceptive supply, condom, male, each |
718 |
636 |
$9K |
| 87491 |
Infectious agent detection by nucleic acid; Chlamydia trachomatis, amplified probe |
108 |
89 |
$2K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
19 |
16 |
$2K |
| 99215 |
Prolong outpt/office vis |
12 |
12 |
$1K |
| 99203 |
Office or other outpatient visit for the evaluation and management of a new patient, low complexity |
15 |
12 |
$1K |
| 99401 |
|
34 |
31 |
$894.96 |
| 87591 |
Infectious agent detection by nucleic acid; Neisseria gonorrhoeae, amplified probe |
72 |
52 |
$726.95 |
| 86780 |
|
39 |
29 |
$276.95 |
| 87800 |
|
22 |
16 |
$271.73 |
| 81025 |
|
56 |
52 |
$250.00 |
| G0433 |
Infectious agent antibody detection by enzyme-linked immunosorbent assay (elisa) technique, hiv-1 and/or hiv-2, screening |
13 |
12 |
$219.36 |
| 86703 |
|
38 |
28 |
$175.52 |
| 36416 |
|
66 |
53 |
$173.83 |
| J8499 |
Prescription drug, oral, non chemotherapeutic, nos |
39 |
29 |
$83.61 |