[
  {
    "Procedure Code": "D0120",
    "Description": "Periodic oral evaluation - established patient",
    "PriceLTEQ21": "31",
    "PriceGT21": "24"
  },
  {
    "Procedure Code": "D0140",
    "Description": "Limited oral evaluation - problem focused",
    "PriceLTEQ21": "49",
    "PriceGT21": "43"
  },
  {
    "Procedure Code": "D0145",
    "Description": "Oral evaluation for a patient under three years of age and counseling with primary caregiver",
    "PriceLTEQ21": "27",
    "PriceGT21": "NC"
  },
  {
    "Procedure Code": "D0150",
    "Description": "Comprehensive oral evaluation - new or established patient",
    "PriceLTEQ21": "62",
    "PriceGT21": "41"
  },
  {
    "Procedure Code": "D0180",
    "Description": "Comprehensive periodontal evaluation - new or established patient",
    "PriceLTEQ21": "58",
    "PriceGT21": "37"
  },
  {
    "Procedure Code": "D0190",
    "Description": "Screening of a patient (PHDH only)",
    "PriceLTEQ21": "29",
    "PriceGT21": "20"
  },
  {
    "Procedure Code": "D0191",
    "Description": "Assessment of a patient (PHDH only)",
    "PriceLTEQ21": "29",
    "PriceGT21": "20"
  },
  {
    "Procedure Code": "D0210",
    "Description": "Intraoral - complete series of radiographic images",
    "PriceLTEQ21": "94",
    "PriceGT21": "76"
  },
  {
    "Procedure Code": "D0220",
    "Description": "Intraoral - periapical, first radiographic image",
    "PriceLTEQ21": "21",
    "PriceGT21": "15"
  },
  {
    "Procedure Code": "D0230",
    "Description": "Intraoral - periapical, each additional radiographic image",
    "PriceLTEQ21": "17",
    "PriceGT21": "13"
  },
  {
    "Procedure Code": "D0240",
    "Description": "Intraoral - occlusal radiographic image",
    "PriceLTEQ21": "26",
    "PriceGT21": "NC"
  },
  {
    "Procedure Code": "D0270",
    "Description": "Bitewing - single radiographic image",
    "PriceLTEQ21": "17",
    "PriceGT21": "14"
  },
  {
    "Procedure Code": "D0272",
    "Description": "Bitewings - two radiographic images",
    "PriceLTEQ21": "32",
    "PriceGT21": "25"
  },
  {
    "Procedure Code": "D0273",
    "Description": "Bitewings - three radiographic images",
    "PriceLTEQ21": "35",
    "PriceGT21": "27"
  },
  {
    "Procedure Code": "D0274",
    "Description": "Bitewings - four radiographic images",
    "PriceLTEQ21": "46",
    "PriceGT21": "36"
  },
  {
    "Procedure Code": "D0330",
    "Description": "Panoramic radiographic image",
    "PriceLTEQ21": "94",
    "PriceGT21": "69"
  },
  {
    "Procedure Code": "D0340",
    "Description": "Cephalometric radiograph image (Oral surgeon only)",
    "PriceLTEQ21": "85",
    "PriceGT21": "74"
  },
  {
    "Procedure Code": "D1110",
    "Description": "Prophylaxis – adult, 14 yo or older",
    "PriceLTEQ21": "75",
    "PriceGT21": "60"
  },
  {
    "Procedure Code": "D1120",
    "Description": "Prophylaxis – child, 0-13 yo",
    "PriceLTEQ21": "55",
    "PriceGT21": "NC"
  },
  {
    "Procedure Code": "D1206",
    "Description": "Topical application of fluoride varnish",
    "PriceLTEQ21": "28",
    "PriceGT21": "26"
  },
  {
    "Procedure Code": "D1208",
    "Description": "Topical application of fluoride – excluding varnish",
    "PriceLTEQ21": "31",
    "PriceGT21": "29"
  },
  {
    "Procedure Code": "D1351",
    "Description": "Sealant – per tooth",
    "PriceLTEQ21": "44",
    "PriceGT21": "NC"
  },
  {
    "Procedure Code": "D1354",
    "Description": "Application of caries arresting medicament - per tooth",
    "PriceLTEQ21": "15",
    "PriceGT21": "15"
  },
  {
    "Procedure Code": "D1510",
    "Description": "Space maintainer – fixed,unilateral – per quadrant",
    "PriceLTEQ21": "229",
    "PriceGT21": "NC"
  },
  {
    "Procedure Code": "D1516",
    "Description": "Space maintainer- fixed- bilateral, maxillary",
    "PriceLTEQ21": "345",
    "PriceGT21": "NC"
  },
  {
    "Procedure Code": "D1517",
    "Description": "Space maintainer- fixed- bilateral, mandibular",
    "PriceLTEQ21": "345",
    "PriceGT21": "NC"
  },
  {
    "Procedure Code": "D1520",
    "Description": "Space maintainer – removable- unilateral- per quadrant",
    "PriceLTEQ21": "244",
    "PriceGT21": "NC"
  },
  {
    "Procedure Code": "D1526",
    "Description": "Space maintainer- removable- bilateral, maxillary",
    "PriceLTEQ21": "368",
    "PriceGT21": "NC"
  },
  {
    "Procedure Code": "D1527",
    "Description": "Space maintainer- removable- bilateral, mandibular",
    "PriceLTEQ21": "368",
    "PriceGT21": "NC"
  },
  {
    "Procedure Code": "D1575",
    "Description": "Distal shoe space maintainer - fixed- unilateral- Per Quadrant I.C",
    "PriceLTEQ21": "NC",
    "PriceGT21": "NC"
  },
  {
    "Procedure Code": "D1701",
    "Description": "Pfizer-BioNTech Covid-19 vaccine administration – first dose SARSCOV2 COVID-19 VAC mRNA 30mcg/0.3mL IM DOSE 1",
    "PriceLTEQ21": "45.87",
    "PriceGT21": "45.87"
  },
  {
    "Procedure Code": "D1702",
    "Description": "Pfizer-BioNTech Covid-19 vaccine administration – second dose SARSCOV2 COVID-19 VAC mRNA 30mcg/0.3mL IM DOSE 2",
    "PriceLTEQ21": "45.87",
    "PriceGT21": "45.87"
  },
  {
    "Procedure Code": "D1707",
    "Description": "Janssen Covid-19 vaccine administration SARSCOV2 COVID-19 VAC Ad26 5x1010 VP/.5mL IM SINGLE DOSE",
    "PriceLTEQ21": "45.87",
    "PriceGT21": "45.87"
  },
  {
    "Procedure Code": "D1708",
    "Description": "Pfizer-BioNTech Covid-19 vaccine administration – third dose",
    "PriceLTEQ21": "45.87",
    "PriceGT21": "45.87"
  },
  {
    "Procedure Code": "D1709",
    "Description": "Pfizer-BioNTech Covid-19 vaccine administration – booster dose",
    "PriceLTEQ21": "45.87",
    "PriceGT21": "45.87"
  },
  {
    "Procedure Code": "D1712",
    "Description": "Janssen Covid-19 vaccine administration - booster dose",
    "PriceLTEQ21": "45.87",
    "PriceGT21": "45.87"
  },
  {
    "Procedure Code": "D1713",
    "Description": "Pfizer-BioNTech Covid-19 vaccine administration tris-sucrose pediatric – first dose",
    "PriceLTEQ21": "45.87",
    "PriceGT21": "45.87"
  },
  {
    "Procedure Code": "D1714",
    "Description": "Pfizer-BioNTech Covid-19 vaccine administration tris-sucrose pediatric – second dose",
    "PriceLTEQ21": "45.87",
    "PriceGT21": "45.87"
  },
  {
    "Procedure Code": "D2140",
    "Description": "Amalgam-one surface, primary or permanent",
    "PriceLTEQ21": "77",
    "PriceGT21": "62"
  },
  {
    "Procedure Code": "D2150",
    "Description": "Amalgam-two surfaces, primary or permanent",
    "PriceLTEQ21": "95",
    "PriceGT21": "77"
  },
  {
    "Procedure Code": "D2160",
    "Description": "Amalgam-three surfaces, primary or permanent",
    "PriceLTEQ21": "110",
    "PriceGT21": "92"
  },
  {
    "Procedure Code": "D2161",
    "Description": "Amalgam-four or more surfaces, primary or permanent",
    "PriceLTEQ21": "137",
    "PriceGT21": "116"
  },
  {
    "Procedure Code": "D2330",
    "Description": "Resin-based composite – one surface, anterior",
    "PriceLTEQ21": "98",
    "PriceGT21": "72"
  },
  {
    "Procedure Code": "D2331",
    "Description": "Resin-based composite – two surfaces, anterior",
    "PriceLTEQ21": "118",
    "PriceGT21": "92"
  },
  {
    "Procedure Code": "D2332",
    "Description": "Resin-based composite – three surfaces, anterior",
    "PriceLTEQ21": "147",
    "PriceGT21": "116"
  },
  {
    "Procedure Code": "D2335",
    "Description": "Resin-based composite – four or more surfaces or involving incisal angle (anterior)",
    "PriceLTEQ21": "188",
    "PriceGT21": "146"
  },
  {
    "Procedure Code": "D2390",
    "Description": "Resin-based composite crown, anterior",
    "PriceLTEQ21": "133",
    "PriceGT21": "NC"
  },
  {
    "Procedure Code": "D2391",
    "Description": "Resin-based composite – one surface, posterior",
    "PriceLTEQ21": "99",
    "PriceGT21": "62"
  },
  {
    "Procedure Code": "D2392",
    "Description": "Resin-based composite – two surfaces, posterior",
    "PriceLTEQ21": "123",
    "PriceGT21": "77"
  },
  {
    "Procedure Code": "D2393",
    "Description": "Resin-based composite – three surfaces, posterior",
    "PriceLTEQ21": "133",
    "PriceGT21": "92"
  },
  {
    "Procedure Code": "D2394",
    "Description": "Resin-based composite – four or more surfaces, posterior",
    "PriceLTEQ21": "182",
    "PriceGT21": "116"
  },
  {
    "Procedure Code": "D2710",
    "Description": "Crown – resin-based composite (indirect)",
    "PriceLTEQ21": "244",
    "PriceGT21": "NC"
  },
  {
    "Procedure Code": "D2740",
    "Description": "Crown – porcelain/ceramic",
    "PriceLTEQ21": "853",
    "PriceGT21": "729"
  },
  {
    "Procedure Code": "D2750",
    "Description": "Crown – porcelain fused to high noble metal",
    "PriceLTEQ21": "800",
    "PriceGT21": "NC"
  },
  {
    "Procedure Code": "D2751",
    "Description": "Crown – porcelain fused to predominantly base metal",
    "PriceLTEQ21": "727",
    "PriceGT21": "613"
  },
  {
    "Procedure Code": "D2752",
    "Description": "Crown – porcelain fused to noble metal",
    "PriceLTEQ21": "735",
    "PriceGT21": "NC"
  },
  {
    "Procedure Code": "D2790",
    "Description": "Crown – full cast high noble metal",
    "PriceLTEQ21": "808",
    "PriceGT21": "NC"
  },
  {
    "Procedure Code": "D2910",
    "Description": "Re-cement or re-bond inlay, onlay or partial coverage restoration",
    "PriceLTEQ21": "69",
    "PriceGT21": "57"
  },
  {
    "Procedure Code": "D2920",
    "Description": "Re-cement or re-bond crown",
    "PriceLTEQ21": "68",
    "PriceGT21": "57"
  },
  {
    "Procedure Code": "D2929",
    "Description": "Prefabricated porcelain/ceramic crown – primary tooth",
    "PriceLTEQ21": "224",
    "PriceGT21": "NC"
  },
  {
    "Procedure Code": "D2930",
    "Description": "Prefabricated stainless steel crown – primary tooth",
    "PriceLTEQ21": "205",
    "PriceGT21": "NC"
  },
  {
    "Procedure Code": "D2932",
    "Description": "Prefabricated resin crown",
    "PriceLTEQ21": "224",
    "PriceGT21": "NC"
  },
  {
    "Procedure Code": "D2934",
    "Description": "Prefabricated esthetic coated stainless steel crown – primary tooth",
    "PriceLTEQ21": "184",
    "PriceGT21": "NC"
  },
  {
    "Procedure Code": "D2950",
    "Description": "Core buildup, including any pins when required",
    "PriceLTEQ21": "197",
    "PriceGT21": "164"
  },
  {
    "Procedure Code": "D2951",
    "Description": "Pin retention – per tooth, in addition to restoration",
    "PriceLTEQ21": "31",
    "PriceGT21": "27"
  },
  {
    "Procedure Code": "D2954",
    "Description": "Prefabricated post and core in addition to crown",
    "PriceLTEQ21": "229",
    "PriceGT21": "191"
  },
  {
    "Procedure Code": "D2980",
    "Description": "Crown repair necessitated by restorative material failure",
    "PriceLTEQ21": "137",
    "PriceGT21": "115"
  },
  {
    "Procedure Code": "D3120",
    "Description": "Pulp cap – indirect (excluding final restoration)",
    "PriceLTEQ21": "40",
    "PriceGT21": "34"
  },
  {
    "Procedure Code": "D3220",
    "Description": "Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament",
    "PriceLTEQ21": "106",
    "PriceGT21": "NC"
  },
  {
    "Procedure Code": "D3310",
    "Description": "Endodontic therapy, anterior (excluding final restoration)",
    "PriceLTEQ21": "544",
    "PriceGT21": "544"
  },
  {
    "Procedure Code": "D3320",
    "Description": "Endodontic therapy, premolar tooth (excluding final restoration)",
    "PriceLTEQ21": "639",
    "PriceGT21": "639"
  },
  {
    "Procedure Code": "D3330",
    "Description": "Endodontic therapy, molar tooth (excluding final restoration)",
    "PriceLTEQ21": "829",
    "PriceGT21": "829"
  },
  {
    "Procedure Code": "D3346",
    "Description": "Retreatment of previous root canal therapy – anterior",
    "PriceLTEQ21": "545",
    "PriceGT21": "456"
  },
  {
    "Procedure Code": "D3347",
    "Description": "Retreatment of previous root canal therapy – premolar",
    "PriceLTEQ21": "641",
    "PriceGT21": "538"
  },
  {
    "Procedure Code": "D3348",
    "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"
  },
  {
    "Procedure Code": "D3425",
    "Description": "Apicoectomy – molar (first root)",
    "PriceLTEQ21": "639",
    "PriceGT21": "598"
  },
  {
    "Procedure Code": "D3426",
    "Description": "Apicoectomy (each additional root)",
    "PriceLTEQ21": "264",
    "PriceGT21": "230"
  },
  {
    "Procedure Code": "D4210",
    "Description": "Gingivectomy or gingivoplasty - Four or more contiguous teeth or bounded teeth spaces per quadrant",
    "PriceLTEQ21": "343",
    "PriceGT21": "307"
  },
  {
    "Procedure Code": "D4211",
    "Description": "Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces per quadrant",
    "PriceLTEQ21": "133",
    "PriceGT21": "111"
  },
  {
    "Procedure Code": "D4341",
    "Description": "Periodontal scaling and root planing - four or more teeth per quadrant",
    "PriceLTEQ21": "160",
    "PriceGT21": "134"
  },
  {
    "Procedure Code": "D4342",
    "Description": "Periodontal scaling and root planing - one to three teeth, per quadrant",
    "PriceLTEQ21": "107",
    "PriceGT21": "90"
  },
  {
    "Procedure Code": "D4346",
    "Description": "Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation",
    "PriceLTEQ21": "75",
    "PriceGT21": "60"
  },
  {
    "Procedure Code": "D5110",
    "Description": "Complete denture – maxillary",
    "PriceLTEQ21": "858",
    "PriceGT21": "730"
  },
  {
    "Procedure Code": "D5120",
    "Description": "Complete denture – mandibular",
    "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"
  }
]