| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 41899 |
Unlisted procedure, dentoalveolar structures |
178 |
161 |
$144K |
| 41820 |
|
56 |
44 |
$8K |
| J3490 |
Unclassified drugs |
104 |
89 |
$35.34 |
| J2704 |
Injection, propofol, 10 mg |
195 |
172 |
$23.00 |
| J1885 |
Injection, ketorolac tromethamine, per 15 mg |
72 |
72 |
$11.04 |
| J2405 |
Injection, ondansetron hydrochloride, per 1 mg |
115 |
103 |
$7.00 |
| J1100 |
Injection, dexamethasone sodium phosphate, 1 mg |
93 |
72 |
$6.00 |
| J3010 |
Injection, fentanyl citrate, 0.1 mg |
87 |
73 |
$4.96 |
| OP710 |
|
291 |
290 |
$4.66 |
| J2250 |
Injection, midazolam hydrochloride, per 1 mg |
12 |
12 |
$3.00 |
| OP259 |
|
159 |
53 |
$1.09 |
| OP250 |
|
422 |
200 |
$0.00 |
| D1203 |
|
27 |
27 |
$0.00 |
| D1110 |
Prophylaxis - adult |
40 |
35 |
$0.00 |
| J7120 |
Ringers lactate infusion, up to 1000 cc |
39 |
26 |
$0.00 |
| OP270 |
|
989 |
298 |
$0.00 |
| OP370 |
|
231 |
231 |
$0.00 |
| A9270 |
Non-covered item or service |
53 |
29 |
$0.00 |
| OP272 |
|
425 |
242 |
$0.00 |
| J2001 |
Injection, lidocaine hcl for intravenous infusion, 10 mg |
12 |
12 |
$0.00 |
| OP271 |
|
17 |
17 |
$0.00 |