1004 lines
27 KiB
JSON
1004 lines
27 KiB
JSON
[
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{
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"Procedure Code": "D0120",
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"Description": "Periodic oral evaluation - established patient",
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"PriceLTEQ21": "31",
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"PriceGT21": "24"
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},
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{
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"Procedure Code": "D0140",
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"Description": "Limited oral evaluation - problem focused",
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"PriceLTEQ21": "49",
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"PriceGT21": "43"
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},
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{
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"Procedure Code": "D0145",
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"Description": "Oral evaluation for a patient under three years of age and counseling with primary caregiver",
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"PriceLTEQ21": "27",
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"PriceGT21": "NC"
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},
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{
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"Procedure Code": "D0150",
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"Description": "Comprehensive oral evaluation - new or established patient",
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"PriceLTEQ21": "62",
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"PriceGT21": "41"
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},
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{
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"Procedure Code": "D0180",
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"Description": "Comprehensive periodontal evaluation - new or established patient",
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"PriceLTEQ21": "58",
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"PriceGT21": "37"
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},
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{
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"Procedure Code": "D0190",
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"Description": "Screening of a patient (PHDH only)",
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"PriceLTEQ21": "29",
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"PriceGT21": "20"
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},
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{
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"Procedure Code": "D0191",
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"Description": "Assessment of a patient (PHDH only)",
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"PriceLTEQ21": "29",
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"PriceGT21": "20"
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},
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{
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"Procedure Code": "D0210",
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"Description": "Intraoral - complete series of radiographic images",
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"PriceLTEQ21": "94",
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"PriceGT21": "76"
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},
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{
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"Procedure Code": "D0220",
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"Description": "Intraoral - periapical, first radiographic image",
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"PriceLTEQ21": "21",
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"PriceGT21": "15"
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},
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{
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"Procedure Code": "D0230",
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"Description": "Intraoral - periapical, each additional radiographic image",
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"PriceLTEQ21": "17",
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"PriceGT21": "13"
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},
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{
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"Procedure Code": "D0240",
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"Description": "Intraoral - occlusal radiographic image",
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"PriceLTEQ21": "26",
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"PriceGT21": "NC"
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},
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{
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"Procedure Code": "D0270",
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"Description": "Bitewing - single radiographic image",
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"PriceLTEQ21": "17",
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"PriceGT21": "14"
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},
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{
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"Procedure Code": "D0272",
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"Description": "Bitewings - two radiographic images",
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"PriceLTEQ21": "32",
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"PriceGT21": "25"
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},
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{
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"Procedure Code": "D0273",
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"Description": "Bitewings - three radiographic images",
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"PriceLTEQ21": "35",
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"PriceGT21": "27"
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},
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{
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"Procedure Code": "D0274",
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"Description": "Bitewings - four radiographic images",
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"PriceLTEQ21": "46",
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"PriceGT21": "36"
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},
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{
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"Procedure Code": "D0330",
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"Description": "Panoramic radiographic image",
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"PriceLTEQ21": "94",
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"PriceGT21": "69"
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},
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{
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"Procedure Code": "D0340",
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"Description": "Cephalometric radiograph image (Oral surgeon only)",
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"PriceLTEQ21": "85",
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"PriceGT21": "74"
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},
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{
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"Procedure Code": "D1110",
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"Description": "Prophylaxis – adult, 14 yo or older",
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"PriceLTEQ21": "75",
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"PriceGT21": "60"
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},
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{
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"Procedure Code": "D1120",
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"Description": "Prophylaxis – child, 0-13 yo",
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"PriceLTEQ21": "55",
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"PriceGT21": "NC"
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},
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{
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"Procedure Code": "D1206",
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"Description": "Topical application of fluoride varnish",
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"PriceLTEQ21": "28",
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"PriceGT21": "26"
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},
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{
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"Procedure Code": "D1208",
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"Description": "Topical application of fluoride – excluding varnish",
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"PriceLTEQ21": "31",
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"PriceGT21": "29"
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},
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{
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"Procedure Code": "D1351",
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"Description": "Sealant – per tooth",
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"PriceLTEQ21": "44",
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"PriceGT21": "NC"
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},
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{
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"Procedure Code": "D1354",
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"Description": "Application of caries arresting medicament - per tooth",
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"PriceLTEQ21": "15",
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"PriceGT21": "15"
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},
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{
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"Procedure Code": "D1510",
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"Description": "Space maintainer – fixed,unilateral – per quadrant",
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"PriceLTEQ21": "229",
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"PriceGT21": "NC"
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},
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{
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"Procedure Code": "D1516",
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"Description": "Space maintainer- fixed- bilateral, maxillary",
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"PriceLTEQ21": "345",
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"PriceGT21": "NC"
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},
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{
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"Procedure Code": "D1517",
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"Description": "Space maintainer- fixed- bilateral, mandibular",
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"PriceLTEQ21": "345",
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"PriceGT21": "NC"
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},
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{
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"Procedure Code": "D1520",
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"Description": "Space maintainer – removable- unilateral- per quadrant",
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"PriceLTEQ21": "244",
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"PriceGT21": "NC"
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},
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{
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"Procedure Code": "D1526",
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"Description": "Space maintainer- removable- bilateral, maxillary",
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"PriceLTEQ21": "368",
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"PriceGT21": "NC"
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},
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{
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"Procedure Code": "D1527",
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"Description": "Space maintainer- removable- bilateral, mandibular",
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"PriceLTEQ21": "368",
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"PriceGT21": "NC"
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},
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{
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"Procedure Code": "D1575",
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"Description": "Distal shoe space maintainer - fixed- unilateral- Per Quadrant I.C",
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"PriceLTEQ21": "NC",
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"PriceGT21": "NC"
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},
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{
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"Procedure Code": "D1701",
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"Description": "Pfizer-BioNTech Covid-19 vaccine administration – first dose SARSCOV2 COVID-19 VAC mRNA 30mcg/0.3mL IM DOSE 1",
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"PriceLTEQ21": "45.87",
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"PriceGT21": "45.87"
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},
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{
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"Procedure Code": "D1702",
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"Description": "Pfizer-BioNTech Covid-19 vaccine administration – second dose SARSCOV2 COVID-19 VAC mRNA 30mcg/0.3mL IM DOSE 2",
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"PriceLTEQ21": "45.87",
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"PriceGT21": "45.87"
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},
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{
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"Procedure Code": "D1707",
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"Description": "Janssen Covid-19 vaccine administration SARSCOV2 COVID-19 VAC Ad26 5x1010 VP/.5mL IM SINGLE DOSE",
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"PriceLTEQ21": "45.87",
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"PriceGT21": "45.87"
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},
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{
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"Procedure Code": "D1708",
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"Description": "Pfizer-BioNTech Covid-19 vaccine administration – third dose",
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"PriceLTEQ21": "45.87",
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"PriceGT21": "45.87"
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},
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{
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"Procedure Code": "D1709",
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"Description": "Pfizer-BioNTech Covid-19 vaccine administration – booster dose",
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"PriceLTEQ21": "45.87",
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"PriceGT21": "45.87"
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},
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{
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"Procedure Code": "D1712",
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"Description": "Janssen Covid-19 vaccine administration - booster dose",
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"PriceLTEQ21": "45.87",
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"PriceGT21": "45.87"
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},
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{
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"Procedure Code": "D1713",
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"Description": "Pfizer-BioNTech Covid-19 vaccine administration tris-sucrose pediatric – first dose",
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"PriceLTEQ21": "45.87",
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"PriceGT21": "45.87"
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},
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{
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"Procedure Code": "D1714",
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"Description": "Pfizer-BioNTech Covid-19 vaccine administration tris-sucrose pediatric – second dose",
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"PriceLTEQ21": "45.87",
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"PriceGT21": "45.87"
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},
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{
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"Procedure Code": "D2140",
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"Description": "Amalgam-one surface, primary or permanent",
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"PriceLTEQ21": "77",
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"PriceGT21": "62"
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},
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{
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"Procedure Code": "D2150",
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"Description": "Amalgam-two surfaces, primary or permanent",
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"PriceLTEQ21": "95",
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"PriceGT21": "77"
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},
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{
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"Procedure Code": "D2160",
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"Description": "Amalgam-three surfaces, primary or permanent",
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"PriceLTEQ21": "110",
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"PriceGT21": "92"
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},
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{
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"Procedure Code": "D2161",
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"Description": "Amalgam-four or more surfaces, primary or permanent",
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"PriceLTEQ21": "137",
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"PriceGT21": "116"
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},
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{
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"Procedure Code": "D2330",
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"Description": "Resin-based composite – one surface, anterior",
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"PriceLTEQ21": "98",
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"PriceGT21": "72"
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},
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{
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"Procedure Code": "D2331",
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"Description": "Resin-based composite – two surfaces, anterior",
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"PriceLTEQ21": "118",
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"PriceGT21": "92"
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},
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{
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"Procedure Code": "D2332",
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"Description": "Resin-based composite – three surfaces, anterior",
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"PriceLTEQ21": "147",
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"PriceGT21": "116"
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},
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{
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"Procedure Code": "D2335",
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"Description": "Resin-based composite – four or more surfaces or involving incisal angle (anterior)",
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"PriceLTEQ21": "188",
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"PriceGT21": "146"
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},
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{
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"Procedure Code": "D2390",
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"Description": "Resin-based composite crown, anterior",
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"PriceLTEQ21": "133",
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"PriceGT21": "NC"
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},
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{
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"Procedure Code": "D2391",
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"Description": "Resin-based composite – one surface, posterior",
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"PriceLTEQ21": "99",
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"PriceGT21": "62"
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},
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{
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"Procedure Code": "D2392",
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"Description": "Resin-based composite – two surfaces, posterior",
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"PriceLTEQ21": "123",
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"PriceGT21": "77"
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},
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{
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"Procedure Code": "D2393",
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"Description": "Resin-based composite – three surfaces, posterior",
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"PriceLTEQ21": "133",
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"PriceGT21": "92"
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},
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{
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"Procedure Code": "D2394",
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"Description": "Resin-based composite – four or more surfaces, posterior",
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"PriceLTEQ21": "182",
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"PriceGT21": "116"
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},
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{
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"Procedure Code": "D2710",
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"Description": "Crown – resin-based composite (indirect)",
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"PriceLTEQ21": "244",
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"PriceGT21": "NC"
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},
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{
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"Procedure Code": "D2740",
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"Description": "Crown – porcelain/ceramic",
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"PriceLTEQ21": "853",
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"PriceGT21": "729"
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},
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{
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"Procedure Code": "D2750",
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"Description": "Crown – porcelain fused to high noble metal",
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"PriceLTEQ21": "800",
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"PriceGT21": "NC"
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},
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{
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"Procedure Code": "D2751",
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"Description": "Crown – porcelain fused to predominantly base metal",
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"PriceLTEQ21": "727",
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"PriceGT21": "613"
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},
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{
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"Procedure Code": "D2752",
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"Description": "Crown – porcelain fused to noble metal",
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"PriceLTEQ21": "735",
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"PriceGT21": "NC"
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},
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{
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"Procedure Code": "D2790",
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"Description": "Crown – full cast high noble metal",
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"PriceLTEQ21": "808",
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"PriceGT21": "NC"
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},
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{
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"Procedure Code": "D2910",
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"Description": "Re-cement or re-bond inlay, onlay or partial coverage restoration",
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"PriceLTEQ21": "69",
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"PriceGT21": "57"
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},
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{
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"Procedure Code": "D2920",
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"Description": "Re-cement or re-bond crown",
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"PriceLTEQ21": "68",
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"PriceGT21": "57"
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},
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{
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"Procedure Code": "D2929",
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"Description": "Prefabricated porcelain/ceramic crown – primary tooth",
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"PriceLTEQ21": "224",
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"PriceGT21": "NC"
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},
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{
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"Procedure Code": "D2930",
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"Description": "Prefabricated stainless steel crown – primary tooth",
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"PriceLTEQ21": "205",
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"PriceGT21": "NC"
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},
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{
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"Procedure Code": "D2932",
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"Description": "Prefabricated resin crown",
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"PriceLTEQ21": "224",
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"PriceGT21": "NC"
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},
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{
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"Procedure Code": "D2934",
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"Description": "Prefabricated esthetic coated stainless steel crown – primary tooth",
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"PriceLTEQ21": "184",
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"PriceGT21": "NC"
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},
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{
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"Procedure Code": "D2950",
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"Description": "Core buildup, including any pins when required",
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"PriceLTEQ21": "197",
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"PriceGT21": "164"
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},
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{
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"Procedure Code": "D2951",
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"Description": "Pin retention – per tooth, in addition to restoration",
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"PriceLTEQ21": "31",
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"PriceGT21": "27"
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},
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{
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"Procedure Code": "D2954",
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"Description": "Prefabricated post and core in addition to crown",
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"PriceLTEQ21": "229",
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"PriceGT21": "191"
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},
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{
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"Procedure Code": "D2980",
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"Description": "Crown repair necessitated by restorative material failure",
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"PriceLTEQ21": "137",
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"PriceGT21": "115"
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},
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{
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"Procedure Code": "D3120",
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"Description": "Pulp cap – indirect (excluding final restoration)",
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"PriceLTEQ21": "40",
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"PriceGT21": "34"
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},
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{
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"Procedure Code": "D3220",
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"Description": "Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament",
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"PriceLTEQ21": "106",
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"PriceGT21": "NC"
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},
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{
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"Procedure Code": "D3310",
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"Description": "Endodontic therapy, anterior (excluding final restoration)",
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"PriceLTEQ21": "544",
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"PriceGT21": "544"
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},
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{
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"Procedure Code": "D3320",
|
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"Description": "Endodontic therapy, premolar tooth (excluding final restoration)",
|
||
"PriceLTEQ21": "639",
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"PriceGT21": "639"
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},
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{
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"Procedure Code": "D3330",
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"Description": "Endodontic therapy, molar tooth (excluding final restoration)",
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"PriceLTEQ21": "829",
|
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"PriceGT21": "829"
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},
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{
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"Procedure Code": "D3346",
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"Description": "Retreatment of previous root canal therapy – anterior",
|
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"PriceLTEQ21": "545",
|
||
"PriceGT21": "456"
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||
},
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{
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"Procedure Code": "D3347",
|
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"Description": "Retreatment of previous root canal therapy – premolar",
|
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"PriceLTEQ21": "641",
|
||
"PriceGT21": "538"
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||
},
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{
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"Procedure Code": "D3348",
|
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"Description": "Retreatment of previous root canal therapy – molar",
|
||
"PriceLTEQ21": "789",
|
||
"PriceGT21": "613"
|
||
},
|
||
{
|
||
"Procedure Code": "D3410",
|
||
"Description": "Apicoectomy – anterior",
|
||
"PriceLTEQ21": "471",
|
||
"PriceGT21": "407"
|
||
},
|
||
{
|
||
"Procedure Code": "D3421",
|
||
"Description": "Apicoectomy – premolar (first root)",
|
||
"PriceLTEQ21": "550",
|
||
"PriceGT21": "460"
|
||
},
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{
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||
"Procedure Code": "D3425",
|
||
"Description": "Apicoectomy – molar (first root)",
|
||
"PriceLTEQ21": "639",
|
||
"PriceGT21": "598"
|
||
},
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||
{
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"Procedure Code": "D3426",
|
||
"Description": "Apicoectomy (each additional root)",
|
||
"PriceLTEQ21": "264",
|
||
"PriceGT21": "230"
|
||
},
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||
{
|
||
"Procedure Code": "D4210",
|
||
"Description": "Gingivectomy or gingivoplasty - Four or more contiguous teeth or bounded teeth spaces per quadrant",
|
||
"PriceLTEQ21": "343",
|
||
"PriceGT21": "307"
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||
},
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{
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"Procedure Code": "D4211",
|
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"Description": "Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces per quadrant",
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||
"PriceLTEQ21": "133",
|
||
"PriceGT21": "111"
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||
},
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||
{
|
||
"Procedure Code": "D4341",
|
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"Description": "Periodontal scaling and root planing - four or more teeth per quadrant",
|
||
"PriceLTEQ21": "160",
|
||
"PriceGT21": "134"
|
||
},
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{
|
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"Procedure Code": "D4342",
|
||
"Description": "Periodontal scaling and root planing - one to three teeth, per quadrant",
|
||
"PriceLTEQ21": "107",
|
||
"PriceGT21": "90"
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},
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{
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"Procedure Code": "D4346",
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"Description": "Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation",
|
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"PriceLTEQ21": "75",
|
||
"PriceGT21": "60"
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||
},
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{
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"Procedure Code": "D5110",
|
||
"Description": "Complete denture – maxillary",
|
||
"PriceLTEQ21": "858",
|
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"PriceGT21": "730"
|
||
},
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{
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"Procedure Code": "D5120",
|
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"Description": "Complete denture – mandibular",
|
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"PriceLTEQ21": "852",
|
||
"PriceGT21": "730"
|
||
},
|
||
{
|
||
"Procedure Code": "D5130",
|
||
"Description": "Immediate denture – maxillary",
|
||
"PriceLTEQ21": "935",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D5140",
|
||
"Description": "Immediate denture - mandibular",
|
||
"PriceLTEQ21": "934",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D5211",
|
||
"Description": "Maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth)",
|
||
"PriceLTEQ21": "650",
|
||
"PriceGT21": "556"
|
||
},
|
||
{
|
||
"Procedure Code": "D5212",
|
||
"Description": "Mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth)",
|
||
"PriceLTEQ21": "691",
|
||
"PriceGT21": "595"
|
||
},
|
||
{
|
||
"Procedure Code": "D5213",
|
||
"Description": "Maxillary partial denture- cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)",
|
||
"PriceLTEQ21": "974",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D5214",
|
||
"Description": "Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)",
|
||
"PriceLTEQ21": "986",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D5225",
|
||
"Description": "Maxillary partial denture- flexible base",
|
||
"PriceLTEQ21": "974",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D5226",
|
||
"Description": "Mandibular partial denture- flexible base",
|
||
"PriceLTEQ21": "986",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D5511",
|
||
"Description": "Repair broken complete denture base, mandibular",
|
||
"PriceLTEQ21": "109",
|
||
"PriceGT21": "85"
|
||
},
|
||
{
|
||
"Procedure Code": "D5512",
|
||
"Description": "Repair broken complete denture base, maxillary",
|
||
"PriceLTEQ21": "109",
|
||
"PriceGT21": "85"
|
||
},
|
||
{
|
||
"Procedure Code": "D5611",
|
||
"Description": "Repair broken resin partial denture base, mandibular",
|
||
"PriceLTEQ21": "93",
|
||
"PriceGT21": "77"
|
||
},
|
||
{
|
||
"Procedure Code": "D5612",
|
||
"Description": "Repair broken resin partial denture base, maxillary",
|
||
"PriceLTEQ21": "93",
|
||
"PriceGT21": "77"
|
||
},
|
||
{
|
||
"Procedure Code": "D5621",
|
||
"Description": "Repair broken cast partial denture base, mandibular",
|
||
"PriceLTEQ21": "121",
|
||
"PriceGT21": "104"
|
||
},
|
||
{
|
||
"Procedure Code": "D5622",
|
||
"Description": "Repair broken cast partial denture base, maxillary",
|
||
"PriceLTEQ21": "121",
|
||
"PriceGT21": "104"
|
||
},
|
||
{
|
||
"Procedure Code": "D5630",
|
||
"Description": "Repair or replace broken retentive/clasping materials – per tooth",
|
||
"PriceLTEQ21": "107",
|
||
"PriceGT21": "99"
|
||
},
|
||
{
|
||
"Procedure Code": "D5640",
|
||
"Description": "Replace broken teeth - per tooth",
|
||
"PriceLTEQ21": "91",
|
||
"PriceGT21": "77"
|
||
},
|
||
{
|
||
"Procedure Code": "D5650",
|
||
"Description": "Add tooth to existing partial denture",
|
||
"PriceLTEQ21": "110",
|
||
"PriceGT21": "92"
|
||
},
|
||
{
|
||
"Procedure Code": "D5660",
|
||
"Description": "Add clasp to existing partial denture per tooth",
|
||
"PriceLTEQ21": "125",
|
||
"PriceGT21": "98"
|
||
},
|
||
{
|
||
"Procedure Code": "D5730",
|
||
"Description": "Reline complete maxillary denture (direct)",
|
||
"PriceLTEQ21": "188",
|
||
"PriceGT21": "158"
|
||
},
|
||
{
|
||
"Procedure Code": "D5731",
|
||
"Description": "Reline lower complete mandibular denture (direct)",
|
||
"PriceLTEQ21": "184",
|
||
"PriceGT21": "173"
|
||
},
|
||
{
|
||
"Procedure Code": "D5740",
|
||
"Description": "Reline maxillary partial denture(chairside)",
|
||
"PriceLTEQ21": "169",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D5741",
|
||
"Description": "Reline mandibular partial denture(chairside)",
|
||
"PriceLTEQ21": "160",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D5750",
|
||
"Description": "Reline complete maxillary denture (indirect)",
|
||
"PriceLTEQ21": "255",
|
||
"PriceGT21": "214"
|
||
},
|
||
{
|
||
"Procedure Code": "D5751",
|
||
"Description": "Reline complete mandibular denture (indirect)",
|
||
"PriceLTEQ21": "256",
|
||
"PriceGT21": "215"
|
||
},
|
||
{
|
||
"Procedure Code": "D5760",
|
||
"Description": "Reline maxillary partial denture (laboratory)",
|
||
"PriceLTEQ21": "252",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D5761",
|
||
"Description": "Reline mandibular partial denture (laboratory)",
|
||
"PriceLTEQ21": "252",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D6241",
|
||
"Description": "Pontic-porcelain fused metal",
|
||
"PriceLTEQ21": "691",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D6751",
|
||
"Description": "Retainer crown-porcelain fused to metal",
|
||
"PriceLTEQ21": "691",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D6930",
|
||
"Description": "Re-cement or re-bond fixed partial denture",
|
||
"PriceLTEQ21": "87",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D6980",
|
||
"Description": "Fixed partial denture repair",
|
||
"PriceLTEQ21": "155",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D7111",
|
||
"Description": "Extraction, coronal remnants - primary tooth",
|
||
"PriceLTEQ21": "80",
|
||
"PriceGT21": "75"
|
||
},
|
||
{
|
||
"Procedure Code": "D7140",
|
||
"Description": "Extraction, erupted tooth or exposed root (elevation and/or forceps removal)",
|
||
"PriceLTEQ21": "107",
|
||
"PriceGT21": "77"
|
||
},
|
||
{
|
||
"Procedure Code": "D7210",
|
||
"Description": "Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated",
|
||
"PriceLTEQ21": "179",
|
||
"PriceGT21": "149"
|
||
},
|
||
{
|
||
"Procedure Code": "D7220",
|
||
"Description": "Removal of impacted tooth - soft tissue",
|
||
"PriceLTEQ21": "223",
|
||
"PriceGT21": "191"
|
||
},
|
||
{
|
||
"Procedure Code": "D7230",
|
||
"Description": "Removal of impacted tooth - partially bony",
|
||
"PriceLTEQ21": "286",
|
||
"PriceGT21": "249"
|
||
},
|
||
{
|
||
"Procedure Code": "D7240",
|
||
"Description": "Removal of impacted tooth - completely bony",
|
||
"PriceLTEQ21": "378",
|
||
"PriceGT21": "295"
|
||
},
|
||
{
|
||
"Procedure Code": "D7250",
|
||
"Description": "Surgical removal of residual tooth roots (cutting procedure)",
|
||
"PriceLTEQ21": "173",
|
||
"PriceGT21": "144"
|
||
},
|
||
{
|
||
"Procedure Code": "D7270",
|
||
"Description": "Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth",
|
||
"PriceLTEQ21": "145",
|
||
"PriceGT21": "106"
|
||
},
|
||
{
|
||
"Procedure Code": "D7280",
|
||
"Description": "Surgical access of an unerupted tooth",
|
||
"PriceLTEQ21": "452",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D7283",
|
||
"Description": "Placement of device to facilitate eruption of impacted tooth",
|
||
"PriceLTEQ21": "84",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D7320",
|
||
"Description": "Alveoloplasty not in conjunction with extractions- four or more teeth or tooth spaces, per quadrant",
|
||
"PriceLTEQ21": "202",
|
||
"PriceGT21": "187"
|
||
},
|
||
{
|
||
"Procedure Code": "D7321",
|
||
"Description": "Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant",
|
||
"PriceLTEQ21": "162",
|
||
"PriceGT21": "149"
|
||
},
|
||
{
|
||
"Procedure Code": "D7340",
|
||
"Description": "Vestibuloplasty - ridge extension (second epithelialization)",
|
||
"PriceLTEQ21": "796",
|
||
"PriceGT21": "747"
|
||
},
|
||
{
|
||
"Procedure Code": "D7350",
|
||
"Description": "Vestibuloplasty - ridge extension (Oral surgeon only)",
|
||
"PriceLTEQ21": "1236",
|
||
"PriceGT21": "943"
|
||
},
|
||
{
|
||
"Procedure Code": "D7410",
|
||
"Description": "Radical excision - lesion diameter up to 1.25cm",
|
||
"PriceLTEQ21": "124",
|
||
"PriceGT21": "115"
|
||
},
|
||
{
|
||
"Procedure Code": "D7411",
|
||
"Description": "Excision of benign lesion greater than 1.25 cm",
|
||
"PriceLTEQ21": "254",
|
||
"PriceGT21": "208"
|
||
},
|
||
{
|
||
"Procedure Code": "D7450",
|
||
"Description": "Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm",
|
||
"PriceLTEQ21": "252",
|
||
"PriceGT21": "248"
|
||
},
|
||
{
|
||
"Procedure Code": "D7451",
|
||
"Description": "Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm",
|
||
"PriceLTEQ21": "343",
|
||
"PriceGT21": "288"
|
||
},
|
||
{
|
||
"Procedure Code": "D7460",
|
||
"Description": "Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm",
|
||
"PriceLTEQ21": "142",
|
||
"PriceGT21": "121"
|
||
},
|
||
{
|
||
"Procedure Code": "D7461",
|
||
"Description": "Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm",
|
||
"PriceLTEQ21": "194",
|
||
"PriceGT21": "143"
|
||
},
|
||
{
|
||
"Procedure Code": "D7471",
|
||
"Description": "Removal of lateral exostosis (maxilla or mandible) (Oral surgeon only)",
|
||
"PriceLTEQ21": "194",
|
||
"PriceGT21": "143"
|
||
},
|
||
{
|
||
"Procedure Code": "D7472",
|
||
"Description": "Removal of torus palatinus (Oral surgeon only)",
|
||
"PriceLTEQ21": "194",
|
||
"PriceGT21": "143"
|
||
},
|
||
{
|
||
"Procedure Code": "D7473",
|
||
"Description": "Removal of torus mandibularis (Oral surgeon only)",
|
||
"PriceLTEQ21": "194",
|
||
"PriceGT21": "143"
|
||
},
|
||
{
|
||
"Procedure Code": "D7961",
|
||
"Description": "Buccal/labial frenectomy (frenulectomy)",
|
||
"PriceLTEQ21": "353",
|
||
"PriceGT21": "107"
|
||
},
|
||
{
|
||
"Procedure Code": "D7962",
|
||
"Description": "Lingual frenectomy (frenulectomy)",
|
||
"PriceLTEQ21": "353",
|
||
"PriceGT21": "107"
|
||
},
|
||
{
|
||
"Procedure Code": "D7963",
|
||
"Description": "Frenuloplasty",
|
||
"PriceLTEQ21": "480",
|
||
"PriceGT21": "416"
|
||
},
|
||
{
|
||
"Procedure Code": "D7970",
|
||
"Description": "Excision of hyperplastic tissue - per arch",
|
||
"PriceLTEQ21": "334",
|
||
"PriceGT21": "246"
|
||
},
|
||
{
|
||
"Procedure Code": "D8010",
|
||
"Description": "Limited orthodontic treamtnent of the primary transition (Orthodontist only)",
|
||
"PriceLTEQ21": "250",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D8020",
|
||
"Description": "Limited orthodontic treatment of the transitional dentition (Orthodontist only)",
|
||
"PriceLTEQ21": "250",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D8030",
|
||
"Description": "Limited orthodontic treatment of the adolescent dentition (Orthodontist only)",
|
||
"PriceLTEQ21": "250",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D8040",
|
||
"Description": "Limited orthodontic treatment of the adult dentition (Orthodontist only)",
|
||
"PriceLTEQ21": "250",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D8070",
|
||
"Description": "Comprehensive orthodontic treatment of the transitional dentition (Orthodontist only)",
|
||
"PriceLTEQ21": "1302",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D8080",
|
||
"Description": "Comprehensive orthodontic treatment of the adolescent dentition (Orthodontist only)",
|
||
"PriceLTEQ21": "1302",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D8090",
|
||
"Description": "Comprehensive orthodontic treatment of the adult dentition (Orthodontist only)",
|
||
"PriceLTEQ21": "1302",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D8660",
|
||
"Description": "Pre-orthodontic treatment examination to monitor growth and development (records fee) (Orthodontist only)",
|
||
"PriceLTEQ21": "136",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D8703",
|
||
"Description": "Replacement of lost or broken retainer- maxillary (Orthodontist only)",
|
||
"PriceLTEQ21": "95",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D8704",
|
||
"Description": "Replacement of lost or broken retainer- mandibular (Orthodontist only)",
|
||
"PriceLTEQ21": "95",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D8999",
|
||
"Description": "Unspecified orthodontic procedure, by report (Orthodontist only) I.C I.C** Y Y**",
|
||
"PriceLTEQ21": "NC",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D9110",
|
||
"Description": "Palliative treatment of dental pain – per visit",
|
||
"PriceLTEQ21": "75",
|
||
"PriceGT21": "36"
|
||
},
|
||
{
|
||
"Procedure Code": "D9222",
|
||
"Description": "Deep sedation/general anesthesia – first 15 minutes",
|
||
"PriceLTEQ21": "109",
|
||
"PriceGT21": "90"
|
||
},
|
||
{
|
||
"Procedure Code": "D9223",
|
||
"Description": "Deep sedation/general anesthesia – each additional 15- minute increment",
|
||
"PriceLTEQ21": "109",
|
||
"PriceGT21": "90"
|
||
},
|
||
{
|
||
"Procedure Code": "D9230",
|
||
"Description": "Analgesia, anxiolysis, inhalation of nitrous oxide",
|
||
"PriceLTEQ21": "22",
|
||
"PriceGT21": "15"
|
||
},
|
||
{
|
||
"Procedure Code": "D9248",
|
||
"Description": "Nonintravenous conscious sedation",
|
||
"PriceLTEQ21": "45",
|
||
"PriceGT21": "45"
|
||
},
|
||
{
|
||
"Procedure Code": "D9310",
|
||
"Description": "Consultation- Diagnostic service provided by dentist or physician other than requesting dentist or physician (Specialist only)",
|
||
"PriceLTEQ21": "54",
|
||
"PriceGT21": "63"
|
||
},
|
||
{
|
||
"Procedure Code": "D9410",
|
||
"Description": "House/extended care facility call, once per facility per day",
|
||
"PriceLTEQ21": "36",
|
||
"PriceGT21": "39"
|
||
},
|
||
{
|
||
"Procedure Code": "D9920",
|
||
"Description": "Behavior management, by report",
|
||
"PriceLTEQ21": "86",
|
||
"PriceGT21": "86"
|
||
},
|
||
{
|
||
"Procedure Code": "D9930",
|
||
"Description": "Treatment of complications (postsurgical) - unusual circumstances, by report",
|
||
"PriceLTEQ21": "66",
|
||
"PriceGT21": "30"
|
||
},
|
||
{
|
||
"Procedure Code": "D9941",
|
||
"Description": "Fabrication of athletic mouthguard",
|
||
"PriceLTEQ21": "85",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D9944",
|
||
"Description": "Occlusal guard - hard appliance, full arch",
|
||
"PriceLTEQ21": "308",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D9945",
|
||
"Description": "Occlusal guard - soft appliance, full arch",
|
||
"PriceLTEQ21": "308",
|
||
"PriceGT21": "NC"
|
||
},
|
||
{
|
||
"Procedure Code": "D9946",
|
||
"Description": "Occlusal guard - hard appliance, partial arch",
|
||
"PriceLTEQ21": "308",
|
||
"PriceGT21": "NC"
|
||
}
|
||
] |