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d91e74c959341ecd1726e0c1f5d52e1522c1b539
DentalManagement09/apps/Frontend/src/assets/data/procedureCodesDeltains.json
T
Gitead d91e74c959 fix: Deltains claim selectors and dedicated fee schedule 
Fixes the transaction-type radio button (was matching nothing; now
targets the real data-testid), and adds a Deltains fee schedule
(seeded from DDMA's prices) so Deltains claims stop falling back to
MassHealth pricing.
2026-09-17 21:00:07 -04:00

1037 lines
26 KiB
JSON
Raw Blame History

[
{
"Procedure Code": "D0120",
"Description": "Periodic oral evaluation - established patient",
"Price": 105
},
{
"Procedure Code": "D0140",
"Description": "Limited oral evaluation - problem focused",
"Price": 90
},
{
"Procedure Code": "D0145",
"Description": "Oral evaluation for a patient under three years of age and counseling with primary caregiver",
"Price": "NC"
},
{
"Procedure Code": "D0150",
"Description": "Comprehensive oral evaluation - new or established patient",
"Price": 120
},
{
"Procedure Code": "D0180",
"Description": "Comprehensive periodontal evaluation - new or established patient",
"Price": 37
},
{
"Procedure Code": "D0190",
"Description": "Screening of a patient (PHDH only)",
"Price": 20
},
{
"Procedure Code": "D0191",
"Description": "Assessment of a patient (PHDH only)",
"Price": 20
},
{
"Procedure Code": "D0210",
"Description": "Intraoral - complete series of radiographic images",
"Price": 120
},
{
"Procedure Code": "D0220",
"Description": "Intraoral - periapical, first radiographic image",
"Price": 60
},
{
"Procedure Code": "D0230",
"Description": "Intraoral - periapical, each additional radiographic image",
"Price": 50
},
{
"Procedure Code": "D0240",
"Description": "Intraoral - occlusal radiographic image",
"Price": "NC"
},
{
"Procedure Code": "D0270",
"Description": "Bitewing - single radiographic image",
"Price": 14
},
{
"Procedure Code": "D0272",
"Description": "Bitewings - two radiographic images",
"Price": 80
},
{
"Procedure Code": "D0273",
"Description": "Bitewings - three radiographic images",
"Price": 27
},
{
"Procedure Code": "D0274",
"Description": "Bitewings - four radiographic images",
"Price": 160
},
{
"Procedure Code": "D0330",
"Description": "Panoramic radiographic image",
"Price": 150
},
{
"Procedure Code": "D0340",
"Description": "Cephalometric radiograph image (Oral surgeon only)",
"Price": 74
},
{
"Procedure Code": "D0364",
"Description": "CBCT - less than one jaw (interpret)",
"Price": 350
},
{
"Procedure Code": "D0365",
"Description": "CBCT - mandible (interpret)",
"Price": 350
},
{
"Procedure Code": "D0366",
"Description": "CBCT - maxilla (interpret)",
"Price": 350
},
{
"Procedure Code": "D0367",
"Description": "CBCT - both jaws (interpret)",
"Price": 400
},
{
"Procedure Code": "D0368",
"Description": "CBCT - include TMJ (interpret)",
"Price": 375
},
{
"Procedure Code": "D0380",
"Description": "CBCT - less than one jaw (capture only)",
"Price": 300
},
{
"Procedure Code": "D0381",
"Description": "CBCT - mandible (capture only)",
"Price": 300
},
{
"Procedure Code": "D0382",
"Description": "CBCT - maxilla (capture only)",
"Price": 300
},
{
"Procedure Code": "D0383",
"Description": "CBCT - both jaws / include TMJ (capture only)",
"Price": 350
},
{
"Procedure Code": "D1110",
"Description": "Prophylaxis - adult, 14 yo or older",
"Price": 150
},
{
"Procedure Code": "D1120",
"Description": "Prophylaxis - child, 0-13 yo",
"Price": 120
},
{
"Procedure Code": "D1206",
"Description": "Topical application of fluoride varnish",
"Price": 26
},
{
"Procedure Code": "D1208",
"Description": "Topical application of fluoride - excluding varnish",
"Price": 90
},
{
"Procedure Code": "D1351",
"Description": "Sealant - per tooth",
"Price": 80
},
{
"Procedure Code": "D1354",
"Description": "Application of caries arresting medicament - per tooth",
"Price": 15
},
{
"Procedure Code": "D1510",
"Description": "Space maintainer - fixed, unilateral - per quadrant",
"Price": "NC"
},
{
"Procedure Code": "D1516",
"Description": "Space maintainer - fixed, bilateral, maxillary",
"Price": "NC"
},
{
"Procedure Code": "D1517",
"Description": "Space maintainer - fixed, bilateral, mandibular",
"Price": "NC"
},
{
"Procedure Code": "D1520",
"Description": "Space maintainer - removable, unilateral, per quadrant",
"Price": "NC"
},
{
"Procedure Code": "D1526",
"Description": "Space maintainer - removable, bilateral, maxillary",
"Price": "NC"
},
{
"Procedure Code": "D1527",
"Description": "Space maintainer - removable, bilateral, mandibular",
"Price": "NC"
},
{
"Procedure Code": "D1575",
"Description": "Distal shoe space maintainer - fixed, unilateral, per quadrant",
"Price": "NC"
},
{
"Procedure Code": "D1701",
"Description": "Pfizer-BioNTech Covid-19 vaccine - first dose",
"Price": 45.87
},
{
"Procedure Code": "D1702",
"Description": "Pfizer-BioNTech Covid-19 vaccine - second dose",
"Price": 45.87
},
{
"Procedure Code": "D1707",
"Description": "Janssen Covid-19 vaccine - single dose",
"Price": 45.87
},
{
"Procedure Code": "D1708",
"Description": "Pfizer-BioNTech Covid-19 vaccine - third dose",
"Price": 45.87
},
{
"Procedure Code": "D1709",
"Description": "Pfizer-BioNTech Covid-19 vaccine - booster dose",
"Price": 45.87
},
{
"Procedure Code": "D1712",
"Description": "Janssen Covid-19 vaccine - booster dose",
"Price": 45.87
},
{
"Procedure Code": "D1713",
"Description": "Pfizer-BioNTech Covid-19 vaccine pediatric - first dose",
"Price": 45.87
},
{
"Procedure Code": "D1714",
"Description": "Pfizer-BioNTech Covid-19 vaccine pediatric - second dose",
"Price": 45.87
},
{
"Procedure Code": "D1999",
"Description": "Unspecified preventive procedure, by report",
"Price": 50
},
{
"Procedure Code": "D2140",
"Description": "Amalgam - one surface, primary or permanent",
"Price": 150
},
{
"Procedure Code": "D2150",
"Description": "Amalgam - two surfaces, primary or permanent",
"Price": 200
},
{
"Procedure Code": "D2160",
"Description": "Amalgam - three surfaces, primary or permanent",
"Price": 92
},
{
"Procedure Code": "D2161",
"Description": "Amalgam - four or more surfaces, primary or permanent",
"Price": 116
},
{
"Procedure Code": "D2330",
"Description": "Resin-based composite - one surface, anterior",
"Price": 180
},
{
"Procedure Code": "D2331",
"Description": "Resin-based composite - two surfaces, anterior",
"Price": 220
},
{
"Procedure Code": "D2332",
"Description": "Resin-based composite - three surfaces, anterior",
"Price": 280
},
{
"Procedure Code": "D2335",
"Description": "Resin-based composite - four or more surfaces or involving incisal angle (anterior)",
"Price": 350
},
{
"Procedure Code": "D2390",
"Description": "Resin-based composite crown, anterior",
"Price": "NC"
},
{
"Procedure Code": "D2391",
"Description": "Resin-based composite - one surface, posterior",
"Price": 200
},
{
"Procedure Code": "D2392",
"Description": "Resin-based composite - two surfaces, posterior",
"Price": 250
},
{
"Procedure Code": "D2393",
"Description": "Resin-based composite - three surfaces, posterior",
"Price": 280
},
{
"Procedure Code": "D2394",
"Description": "Resin-based composite - four or more surfaces, posterior",
"Price": 320
},
{
"Procedure Code": "D2710",
"Description": "Crown - resin-based composite (indirect)",
"Price": "NC"
},
{
"Procedure Code": "D2740",
"Description": "Crown - porcelain/ceramic",
"Price": 1300
},
{
"Procedure Code": "D2750",
"Description": "Crown - porcelain fused to high noble metal",
"Price": 1300
},
{
"Procedure Code": "D2751",
"Description": "Crown - porcelain fused to predominantly base metal",
"Price": 1200
},
{
"Procedure Code": "D2752",
"Description": "Crown - porcelain fused to noble metal",
"Price": 1200
},
{
"Procedure Code": "D2790",
"Description": "Crown - full cast high noble metal",
"Price": "NC"
},
{
"Procedure Code": "D2910",
"Description": "Re-cement or re-bond inlay, onlay or partial coverage restoration",
"Price": 57
},
{
"Procedure Code": "D2920",
"Description": "Re-cement or re-bond crown",
"Price": 120
},
{
"Procedure Code": "D2929",
"Description": "Prefabricated porcelain/ceramic crown - primary tooth",
"Price": "NC"
},
{
"Procedure Code": "D2930",
"Description": "Prefabricated stainless steel crown - primary tooth",
"Price": "NC"
},
{
"Procedure Code": "D2931",
"Description": "Prefabricated stainless steel crown - permanent tooth",
"Price": 171
},
{
"Procedure Code": "D2932",
"Description": "Prefabricated resin crown",
"Price": "NC"
},
{
"Procedure Code": "D2934",
"Description": "Prefabricated esthetic coated stainless steel crown - primary tooth",
"Price": "NC"
},
{
"Procedure Code": "D2950",
"Description": "Core buildup, including any pins when required",
"Price": 350
},
{
"Procedure Code": "D2951",
"Description": "Pin retention - per tooth, in addition to restoration",
"Price": 27
},
{
"Procedure Code": "D2954",
"Description": "Prefabricated post and core in addition to crown",
"Price": 450
},
{
"Procedure Code": "D2955",
"Description": "Post removal",
"Price": 350
},
{
"Procedure Code": "D2980",
"Description": "Crown repair necessitated by restorative material failure",
"Price": 115
},
{
"Procedure Code": "D2999",
"Description": "Unspecified restorative procedure, by report",
"Price": "IC"
},
{
"Procedure Code": "D3120",
"Description": "Pulp cap - indirect (excluding final restoration)",
"Price": 34
},
{
"Procedure Code": "D3220",
"Description": "Therapeutic pulpotomy (excluding final restoration)",
"Price": "NC"
},
{
"Procedure Code": "D3230",
"Description": "Pulpal therapy (resorbable filling) - anterior, primary tooth",
"Price": 280
},
{
"Procedure Code": "D3240",
"Description": "Pulpal therapy (resorbable filling) - posterior, primary tooth",
"Price": 490
},
{
"Procedure Code": "D3310",
"Description": "Endodontic therapy, anterior tooth (excluding final restoration)",
"Price": 900
},
{
"Procedure Code": "D3320",
"Description": "Endodontic therapy, premolar tooth (excluding final restoration)",
"Price": 1050
},
{
"Procedure Code": "D3330",
"Description": "Endodontic therapy, molar tooth (excluding final restoration)",
"Price": 1250
},
{
"Procedure Code": "D3346",
"Description": "Retreatment of previous root canal therapy - anterior",
"Price": 950
},
{
"Procedure Code": "D3347",
"Description": "Retreatment of previous root canal therapy - premolar",
"Price": 1100
},
{
"Procedure Code": "D3348",
"Description": "Retreatment of previous root canal therapy - molar",
"Price": 1500
},
{
"Procedure Code": "D3410",
"Description": "Apicoectomy - anterior",
"Price": 407
},
{
"Procedure Code": "D3421",
"Description": "Apicoectomy - premolar (first root)",
"Price": 460
},
{
"Procedure Code": "D3425",
"Description": "Apicoectomy - molar (first root)",
"Price": 598
},
{
"Procedure Code": "D3426",
"Description": "Apicoectomy (each additional root)",
"Price": 230
},
{
"Procedure Code": "D4210",
"Description": "Gingivectomy or gingivoplasty - four or more contiguous teeth per quadrant",
"Price": 307
},
{
"Procedure Code": "D4211",
"Description": "Gingivectomy or gingivoplasty - one to three contiguous teeth per quadrant",
"Price": 111
},
{
"Procedure Code": "D4341",
"Description": "Periodontal scaling and root planing - four or more teeth per quadrant",
"Price": 250
},
{
"Procedure Code": "D4342",
"Description": "Periodontal scaling and root planing - one to three teeth, per quadrant",
"Price": 90
},
{
"Procedure Code": "D4346",
"Description": "Scaling in presence of generalized moderate or severe gingival inflammation - full mouth",
"Price": 60
},
{
"Procedure Code": "D4910",
"Description": "Periodontal maintenance",
"Price": 250
},
{
"Procedure Code": "D5110",
"Description": "Complete denture - maxillary",
"Price": 1700
},
{
"Procedure Code": "D5120",
"Description": "Complete denture - mandibular",
"Price": 1700
},
{
"Procedure Code": "D5130",
"Description": "Immediate denture - maxillary",
"Price": "NC"
},
{
"Procedure Code": "D5140",
"Description": "Immediate denture - mandibular",
"Price": "NC"
},
{
"Procedure Code": "D5211",
"Description": "Maxillary partial denture - resin base",
"Price": 1300
},
{
"Procedure Code": "D5212",
"Description": "Mandibular partial denture - resin base",
"Price": 1300
},
{
"Procedure Code": "D5213",
"Description": "Maxillary partial denture - cast metal framework with resin denture bases",
"Price": 1700
},
{
"Procedure Code": "D5214",
"Description": "Mandibular partial denture - cast metal framework with resin denture bases",
"Price": 1700
},
{
"Procedure Code": "D5225",
"Description": "Maxillary partial denture - flexible base",
"Price": "NC"
},
{
"Procedure Code": "D5226",
"Description": "Mandibular partial denture - flexible base",
"Price": "NC"
},
{
"Procedure Code": "D5510",
"Description": "Repair broken complete denture base (QUAD)",
"Price": 400
},
{
"Procedure Code": "D5511",
"Description": "Repair broken complete denture base, mandibular",
"Price": 85
},
{
"Procedure Code": "D5512",
"Description": "Repair broken complete denture base, maxillary",
"Price": 85
},
{
"Procedure Code": "D5520",
"Description": "Replace missing or broken teeth - complete denture (each tooth)",
"Price": 200
},
{
"Procedure Code": "D5611",
"Description": "Repair broken resin partial denture base, mandibular",
"Price": 77
},
{
"Procedure Code": "D5612",
"Description": "Repair broken resin partial denture base, maxillary",
"Price": 77
},
{
"Procedure Code": "D5621",
"Description": "Repair broken cast partial denture base, mandibular",
"Price": 104
},
{
"Procedure Code": "D5622",
"Description": "Repair broken cast partial denture base, maxillary",
"Price": 104
},
{
"Procedure Code": "D5630",
"Description": "Repair or replace broken retentive/clasping materials - per tooth",
"Price": 99
},
{
"Procedure Code": "D5640",
"Description": "Replace broken teeth - per tooth",
"Price": 77
},
{
"Procedure Code": "D5650",
"Description": "Add tooth to existing partial denture",
"Price": 92
},
{
"Procedure Code": "D5660",
"Description": "Add clasp to existing partial denture per tooth",
"Price": 98
},
{
"Procedure Code": "D5730",
"Description": "Reline complete maxillary denture (chairside)",
"Price": 500
},
{
"Procedure Code": "D5731",
"Description": "Reline complete mandibular denture (chairside)",
"Price": 500
},
{
"Procedure Code": "D5740",
"Description": "Reline maxillary partial denture (chairside)",
"Price": "NC"
},
{
"Procedure Code": "D5741",
"Description": "Reline mandibular partial denture (chairside)",
"Price": "NC"
},
{
"Procedure Code": "D5750",
"Description": "Reline complete maxillary denture (laboratory)",
"Price": 600
},
{
"Procedure Code": "D5751",
"Description": "Reline complete mandibular denture (laboratory)",
"Price": 600
},
{
"Procedure Code": "D5760",
"Description": "Reline maxillary partial denture (laboratory)",
"Price": "NC"
},
{
"Procedure Code": "D5761",
"Description": "Reline mandibular partial denture (laboratory)",
"Price": "NC"
},
{
"Procedure Code": "D6010",
"Description": "Surgical placement of implant body",
"Price": 1600
},
{
"Procedure Code": "D6056",
"Description": "Prefabricated abutment",
"Price": 750
},
{
"Procedure Code": "D6057",
"Description": "Custom abutment",
"Price": 800
},
{
"Procedure Code": "D6058",
"Description": "Implant crown - porcelain/ceramic",
"Price": 1400
},
{
"Procedure Code": "D6059",
"Description": "Implant crown - PFM",
"Price": 1400
},
{
"Procedure Code": "D6100",
"Description": "Surgical removal of implant body",
"Price": 320
},
{
"Procedure Code": "D6110",
"Description": "Implant/abutment supported removable denture - maxillary",
"Price": 1600
},
{
"Procedure Code": "D6111",
"Description": "Implant/abutment supported removable denture - mandibular",
"Price": 1600
},
{
"Procedure Code": "D6241",
"Description": "Pontic - porcelain fused to metal",
"Price": "NC"
},
{
"Procedure Code": "D6242",
"Description": "Pontic - noble metal",
"Price": 1400
},
{
"Procedure Code": "D6245",
"Description": "Pontic - porcelain/ceramic",
"Price": 1400
},
{
"Procedure Code": "D6751",
"Description": "Retainer crown - porcelain fused to metal",
"Price": "NC"
},
{
"Procedure Code": "D6930",
"Description": "Re-cement or re-bond fixed partial denture",
"Price": "NC"
},
{
"Procedure Code": "D6980",
"Description": "Fixed partial denture repair",
"Price": "NC"
},
{
"Procedure Code": "D6999",
"Description": "Fixed prosthodontic procedure, by report",
"Price": "IC"
},
{
"Procedure Code": "D7111",
"Description": "Extraction, coronal remnants - primary tooth",
"Price": 120
},
{
"Procedure Code": "D7140",
"Description": "Extraction, erupted tooth or exposed root (simple)",
"Price": 150
},
{
"Procedure Code": "D7210",
"Description": "Extraction, erupted tooth requiring removal of bone and/or sectioning (surgical)",
"Price": 280
},
{
"Procedure Code": "D7220",
"Description": "Removal of impacted tooth - soft tissue",
"Price": 380
},
{
"Procedure Code": "D7230",
"Description": "Removal of impacted tooth - partially bony",
"Price": 450
},
{
"Procedure Code": "D7240",
"Description": "Removal of impacted tooth - completely bony",
"Price": 550
},
{
"Procedure Code": "D7250",
"Description": "Surgical removal of residual tooth roots",
"Price": 280
},
{
"Procedure Code": "D7251",
"Description": "Coronectomy - intentional partial tooth removal, impacted teeth only",
"Price": 134
},
{
"Procedure Code": "D7270",
"Description": "Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth",
"Price": 106
},
{
"Procedure Code": "D7280",
"Description": "Surgical access of an unerupted tooth",
"Price": "NC"
},
{
"Procedure Code": "D7283",
"Description": "Placement of device to facilitate eruption of impacted tooth",
"Price": "NC"
},
{
"Procedure Code": "D7310",
"Description": "Alveoloplasty in conjunction with extractions - four or more teeth per quadrant",
"Price": 142
},
{
"Procedure Code": "D7311",
"Description": "Alveoloplasty in conjunction with extractions - one to three teeth per quadrant",
"Price": 128
},
{
"Procedure Code": "D7320",
"Description": "Alveoloplasty not in conjunction with extractions - four or more teeth per quadrant",
"Price": 187
},
{
"Procedure Code": "D7321",
"Description": "Alveoloplasty not in conjunction with extractions - one to three teeth per quadrant",
"Price": 149
},
{
"Procedure Code": "D7340",
"Description": "Vestibuloplasty - ridge extension (second epithelialization)",
"Price": 747
},
{
"Procedure Code": "D7350",
"Description": "Vestibuloplasty - ridge extension (Oral surgeon only)",
"Price": 943
},
{
"Procedure Code": "D7410",
"Description": "Excision of benign lesion - diameter up to 1.25 cm",
"Price": 115
},
{
"Procedure Code": "D7411",
"Description": "Excision of benign lesion - diameter greater than 1.25 cm",
"Price": 208
},
{
"Procedure Code": "D7450",
"Description": "Removal of benign odontogenic cyst or tumor - up to 1.25 cm",
"Price": 248
},
{
"Procedure Code": "D7451",
"Description": "Removal of benign odontogenic cyst or tumor - greater than 1.25 cm",
"Price": 288
},
{
"Procedure Code": "D7460",
"Description": "Removal of benign nonodontogenic cyst or tumor - up to 1.25 cm",
"Price": 121
},
{
"Procedure Code": "D7461",
"Description": "Removal of benign nonodontogenic cyst or tumor - greater than 1.25 cm",
"Price": 143
},
{
"Procedure Code": "D7471",
"Description": "Removal of lateral exostosis (maxilla or mandible)",
"Price": 143
},
{
"Procedure Code": "D7472",
"Description": "Removal of torus palatinus",
"Price": 143
},
{
"Procedure Code": "D7473",
"Description": "Removal of torus mandibularis",
"Price": 143
},
{
"Procedure Code": "D7910",
"Description": "Suture of recent small wounds up to 5 cm",
"Price": 400
},
{
"Procedure Code": "D7950",
"Description": "Bone graft - maxilla/mandible",
"Price": 800
},
{
"Procedure Code": "D7953",
"Description": "Bone graft for socket preservation after extraction",
"Price": 800
},
{
"Procedure Code": "D7961",
"Description": "Buccal/labial frenectomy (frenulectomy)",
"Price": 107
},
{
"Procedure Code": "D7962",
"Description": "Lingual frenectomy (frenulectomy)",
"Price": 107
},
{
"Procedure Code": "D7963",
"Description": "Frenuloplasty",
"Price": 416
},
{
"Procedure Code": "D7970",
"Description": "Excision of hyperplastic tissue - per arch",
"Price": 246
},
{
"Procedure Code": "D7999",
"Description": "Unspecified oral surgery procedure, by report",
"Price": "IC"
},
{
"Procedure Code": "D8010",
"Description": "Limited orthodontic treatment of the primary dentition (Orthodontist only)",
"Price": "NC"
},
{
"Procedure Code": "D8020",
"Description": "Limited orthodontic treatment of the transitional dentition (Orthodontist only)",
"Price": "NC"
},
{
"Procedure Code": "D8030",
"Description": "Limited orthodontic treatment of the adolescent dentition (Orthodontist only)",
"Price": "NC"
},
{
"Procedure Code": "D8040",
"Description": "Limited orthodontic treatment of the adult dentition (Orthodontist only)",
"Price": "NC"
},
{
"Procedure Code": "D8070",
"Description": "Comprehensive orthodontic treatment of the transitional dentition (Orthodontist only)",
"Price": "NC"
},
{
"Procedure Code": "D8080",
"Description": "Comprehensive orthodontic treatment of the adolescent dentition (Orthodontist only)",
"Price": "NC"
},
{
"Procedure Code": "D8090",
"Description": "Comprehensive orthodontic treatment of the adult dentition (Orthodontist only)",
"Price": "NC"
},
{
"Procedure Code": "D8660",
"Description": "Pre-orthodontic treatment examination (Orthodontist only)",
"Price": "NC"
},
{
"Procedure Code": "D8670",
"Description": "Periodic orthodontic treatment visit (Orthodontist only)",
"Price": 215
},
{
"Procedure Code": "D8680",
"Description": "Orthodontic retention (Orthodontist only)",
"Price": 85
},
{
"Procedure Code": "D8703",
"Description": "Replacement of lost or broken retainer - maxillary (Orthodontist only)",
"Price": "NC"
},
{
"Procedure Code": "D8704",
"Description": "Replacement of lost or broken retainer - mandibular (Orthodontist only)",
"Price": "NC"
},
{
"Procedure Code": "D8999",
"Description": "Unspecified orthodontic procedure, by report (Orthodontist only)",
"Price": "NC"
},
{
"Procedure Code": "D9110",
"Description": "Palliative treatment of dental pain - per visit",
"Price": 36
},
{
"Procedure Code": "D9222",
"Description": "Deep sedation/general anesthesia - first 15 minutes",
"Price": 90
},
{
"Procedure Code": "D9223",
"Description": "Deep sedation/general anesthesia - each additional 15-minute increment",
"Price": 90
},
{
"Procedure Code": "D9230",
"Description": "Analgesia, anxiolysis, inhalation of nitrous oxide",
"Price": 15
},
{
"Procedure Code": "D9248",
"Description": "Nonintravenous conscious sedation",
"Price": 45
},
{
"Procedure Code": "D9310",
"Description": "Consultation - diagnostic service (Specialist only)",
"Price": 63
},
{
"Procedure Code": "D9410",
"Description": "House/extended care facility call, once per facility per day",
"Price": 39
},
{
"Procedure Code": "D9450",
"Description": "Rural add-on encounter payment",
"Price": 31
},
{
"Procedure Code": "D9920",
"Description": "Behavior management, by report",
"Price": 86
},
{
"Procedure Code": "D9930",
"Description": "Treatment of complications (postsurgical) - unusual circumstances, by report",
"Price": 30
},
{
"Procedure Code": "D9941",
"Description": "Fabrication of athletic mouthguard",
"Price": "NC"
},
{
"Procedure Code": "D9944",
"Description": "Occlusal guard - hard appliance, full arch",
"Price": "NC"
},
{
"Procedure Code": "D9945",
"Description": "Occlusal guard - soft appliance, full arch",
"Price": "NC"
},
{
"Procedure Code": "D9946",
"Description": "Occlusal guard - hard appliance, partial arch",
"Price": "NC"
},
{
"Procedure Code": "D9999",
"Description": "Unspecified adjunctive procedure, by report",
"Price": "IC"
}
]
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