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Superbill Request
Date of Service
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Location of Service
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Location of Service Address
This is the dentist's office address
Surgeon/Dentist's Name
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Patient Name
Patient DOB
Patient Address
Parent/Guardian Name
Additional Diagnosis Code(s)
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F84.0 Autism
F90.2 ADHD
J45.909 Asthma
Anesthesia Time
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Anesthesia Time: 15 BILLING CODES FOR DENTAL INSURANCE CARRIERS: Billing units: 1 unit = 15 minutes Total units for case: 1 HCPCS:D9222, Modifier:AA, General Anesthesia Services (first 15 minutes) = $599 (1 unit) HCPCS:D9223, Modifier:AA, General Anesthesia Services (each subsequent 15 minutes) = 0(0 units) Total amount paid by insured = $599
Anesthesia Time: 30 BILLING CODES FOR DENTAL INSURANCE CARRIERS: Billing units: 1 unit = 15 minutes Total units for case: 2 HCPCS:D9222, Modifier:AA, General Anesthesia Services (first 15 minutes) = $599 (1 unit) HCPCS:D9223, Modifier:AA, General Anesthesia Services (each subsequent 15 minutes) = $165 (1 units) Total amount paid by insured = $764
Anesthesia Time: 45 BILLING CODES FOR DENTAL INSURANCE CARRIERS: Billing units: 1 unit = 15 minutes Total units for case: 3 HCPCS:D9222, Modifier:AA, General Anesthesia Services (first 15 minutes) = $599 (1 unit) HCPCS:D9223, Modifier:AA, General Anesthesia Services (each subsequent 15 minutes) = $330 (2 units) Total amount paid by insured = $929
Anesthesia Time: 60 BILLING CODES FOR DENTAL INSURANCE CARRIERS: Billing units: 1 unit = 15 minutes Total units for case: 4 HCPCS:D9222, Modifier:AA, General Anesthesia Services (first 15 minutes) = $599 (1 unit) HCPCS:D9223, Modifier:AA, General Anesthesia Services (each subsequent 15 minutes) = $495 (3 units) Total amount paid by insured = $1,094
Anesthesia Time: 75 BILLING CODES FOR DENTAL INSURANCE CARRIERS: Billing units: 1 unit = 15 minutes Total units for case: 5 HCPCS:D9222, Modifier:AA, General Anesthesia Services (first 15 minutes) = $599 (1 unit) HCPCS:D9223, Modifier:AA, General Anesthesia Services (each subsequent 15 minutes) = $660 (4 units) Total amount paid by insured = $1,259
Anesthesia Time: 90 BILLING CODES FOR DENTAL INSURANCE CARRIERS: Billing units: 1 unit = 15 minutes Total units for case: 6 HCPCS:D9222, Modifier:AA, General Anesthesia Services (first 15 minutes) = $599 (1 unit) HCPCS:D9223, Modifier:AA, General Anesthesia Services (each subsequent 15 minutes) = $825 (5 units) Total amount paid by insured = $1,424
Anesthesia Time: 105 BILLING CODES FOR DENTAL INSURANCE CARRIERS: Billing units: 1 unit = 15 minutes Total units for case: 7 HCPCS:D9222, Modifier:AA, General Anesthesia Services (first 15 minutes) = $599 (1 unit) HCPCS:D9223, Modifier:AA, General Anesthesia Services (each subsequent 15 minutes) = $990 (6 units) Total amount paid by insured = $1,589
Anesthesia Time: 120 BILLING CODES FOR DENTAL INSURANCE CARRIERS: Billing units: 1 unit = 15 minutes Total units for case: 8 HCPCS:D9222, Modifier:AA, General Anesthesia Services (first 15 minutes) = $599 (1 unit) HCPCS:D9223, Modifier:AA, General Anesthesia Services (each subsequent 15 minutes) = $1,155 (7 units) Total amount paid by insured = $1,754
Anesthesia Time: 135 BILLING CODES FOR DENTAL INSURANCE CARRIERS: Billing units: 1 unit = 15 minutes Total units for case: 9 HCPCS:D9222, Modifier:AA, General Anesthesia Services (first 15 minutes) = $599 (1 unit) HCPCS:D9223, Modifier:AA, General Anesthesia Services (each subsequent 15 minutes) = $1,320 (8 units) Total amount paid by insured = $1,919
Anesthesia Time: 150 BILLING CODES FOR DENTAL INSURANCE CARRIERS: Billing units: 1 unit = 15 minutes Total units for case: 10 HCPCS:D9222, Modifier:AA, General Anesthesia Services (first 15 minutes) = $599 (1 unit) HCPCS:D9223, Modifier:AA, General Anesthesia Services (each subsequent 15 minutes) = $1,485 (9 units) Total amount paid by insured = $2,084
Anesthesia Time: 165 BILLING CODES FOR DENTAL INSURANCE CARRIERS: Billing units: 1 unit = 15 minutes Total units for case: 11 HCPCS:D9222, Modifier:AA, General Anesthesia Services (first 15 minutes) = $599 (1 unit) HCPCS:D9223, Modifier:AA, General Anesthesia Services (each subsequent 15 minutes) = $1,650 (10 units) Total amount paid by insured = $2,249
Anesthesia Time: 180 BILLING CODES FOR DENTAL INSURANCE CARRIERS: Billing units: 1 unit = 15 minutes Total units for case: 12 HCPCS:D9222, Modifier:AA, General Anesthesia Services (first 15 minutes) = $599 (1 unit) HCPCS:D9223, Modifier:AA, General Anesthesia Services (each subsequent 15 minutes) = $1,815 (11 units) Total amount paid by insured = $2,414
Anesthesia Time: 195 BILLING CODES FOR DENTAL INSURANCE CARRIERS: Billing units: 1 unit = 15 minutes Total units for case: 13 HCPCS:D9222, Modifier:AA, General Anesthesia Services (first 15 minutes) = $599 (1 unit) HCPCS:D9223, Modifier:AA, General Anesthesia Services (each subsequent 15 minutes) = $1,980 (12 units) Total amount paid by insured = $2,579
Anesthesia Time: 210 BILLING CODES FOR DENTAL INSURANCE CARRIERS: Billing units: 1 unit = 15 minutes Total units for case: 14 HCPCS:D9222, Modifier:AA, General Anesthesia Services (first 15 minutes) = $599 (1 unit) HCPCS:D9223, Modifier:AA, General Anesthesia Services (each subsequent 15 minutes) = $2,145 (13 units) Total amount paid by insured = $2,744
Anesthesia Time: 225 BILLING CODES FOR DENTAL INSURANCE CARRIERS: Billing units: 1 unit = 15 minutes Total units for case: 15 HCPCS:D9222, Modifier:AA, General Anesthesia Services (first 15 minutes) = $599 (1 unit) HCPCS:D9223, Modifier:AA, General Anesthesia Services (each subsequent 15 minutes) = $2,310 (14 units) Total amount paid by insured = $2,909
Anesthesia Time: 240 BILLING CODES FOR DENTAL INSURANCE CARRIERS: Billing units: 1 unit = 15 minutes Total units for case: 16 HCPCS:D9222, Modifier:AA, General Anesthesia Services (first 15 minutes) = $599 (1 unit) HCPCS:D9223, Modifier:AA, General Anesthesia Services (each subsequent 15 minutes) = $2,475 (15 units) Total amount paid by insured = $3,074
Anesthesia Time: 255 BILLING CODES FOR DENTAL INSURANCE CARRIERS: Billing units: 1 unit = 15 minutes Total units for case: 17 HCPCS:D9222, Modifier:AA, General Anesthesia Services (first 15 minutes) = $599 (1 unit) HCPCS:D9223, Modifier:AA, General Anesthesia Services (each subsequent 15 minutes) = $2,640 (16 units) Total amount paid by insured = $3,239
Anesthesia Time: 270 BILLING CODES FOR DENTAL INSURANCE CARRIERS: Billing units: 1 unit = 15 minutes Total units for case: 18 HCPCS:D9222, Modifier:AA, General Anesthesia Services (first 15 minutes) = $599 (1 unit) HCPCS:D9223, Modifier:AA, General Anesthesia Services (each subsequent 15 minutes) = $2,805 (17 units) Total amount paid by insured = $3,404
Anesthesia Time: 285 BILLING CODES FOR DENTAL INSURANCE CARRIERS: Billing units: 1 unit = 15 minutes Total units for case: 19 HCPCS:D9222, Modifier:AA, General Anesthesia Services (first 15 minutes) = $599 (1 unit) HCPCS:D9223, Modifier:AA, General Anesthesia Services (each subsequent 15 minutes) = $2,970 (18 units) Total amount paid by insured = $3,569
Anesthesia Time: 300 BILLING CODES FOR DENTAL INSURANCE CARRIERS: Billing units: 1 unit = 15 minutes Total units for case: 20 HCPCS:D9222, Modifier:AA, General Anesthesia Services (first 15 minutes) = $599 (1 unit) HCPCS:D9223, Modifier:AA, General Anesthesia Services (each subsequent 15 minutes) = $3,135 (19 units) Total amount paid by insured = $3,734
superbillTEST-02 (Copy)
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