1027 lines
26 KiB
JSON
1027 lines
26 KiB
JSON
[
|
||
{
|
||
"Procedure Code": "D0120",
|
||
"Description": "perio exam",
|
||
"Price": "105"
|
||
},
|
||
{
|
||
"Procedure Code": "D0140",
|
||
"Description": "limited exam",
|
||
"Price": "90"
|
||
},
|
||
{
|
||
"Procedure Code": "D0150",
|
||
"Description": "comprehensive exam",
|
||
"Price": "120"
|
||
},
|
||
{
|
||
"Procedure Code": "D0210",
|
||
"Description": "Fmx.",
|
||
"Price": "120"
|
||
},
|
||
{
|
||
"Procedure Code": "D0220",
|
||
"Description": "first PA.",
|
||
"Price": "60"
|
||
},
|
||
{
|
||
"Procedure Code": "D0230",
|
||
"Description": "2nd PA.",
|
||
"Price": "50"
|
||
},
|
||
{
|
||
"Procedure Code": "D0272",
|
||
"Description": "2 BW",
|
||
"Price": "80"
|
||
},
|
||
{
|
||
"Procedure Code": "D0274",
|
||
"Description": "4BW",
|
||
"Price": "160"
|
||
},
|
||
{
|
||
"Procedure Code": "D0330",
|
||
"Description": "pano",
|
||
"Price": "150"
|
||
},
|
||
{
|
||
"Procedure Code": "D0364",
|
||
"Description": "Less than one jaw",
|
||
"Price": "350"
|
||
},
|
||
{
|
||
"Procedure Code": "D0365",
|
||
"Description": "Mand",
|
||
"Price": "350"
|
||
},
|
||
{
|
||
"Procedure Code": "D0366",
|
||
"Description": "Max",
|
||
"Price": "350"
|
||
},
|
||
{
|
||
"Procedure Code": "D0367",
|
||
"Description": "",
|
||
"Price": "400"
|
||
},
|
||
{
|
||
"Procedure Code": "D0368",
|
||
"Description": "include TMJ",
|
||
"Price": "375"
|
||
},
|
||
{
|
||
"Procedure Code": "D0380",
|
||
"Description": "Less than one jaw",
|
||
"Price": "300"
|
||
},
|
||
{
|
||
"Procedure Code": "D0381",
|
||
"Description": "Mand",
|
||
"Price": "300"
|
||
},
|
||
{
|
||
"Procedure Code": "D0382",
|
||
"Description": "Max",
|
||
"Price": "300"
|
||
},
|
||
{
|
||
"Procedure Code": "D0383",
|
||
"Description": "",
|
||
"Price": "350"
|
||
},
|
||
{
|
||
"Procedure Code": "D1110",
|
||
"Description": "adult prophy",
|
||
"Price": "150"
|
||
},
|
||
{
|
||
"Procedure Code": "D1120",
|
||
"Description": "child prophy",
|
||
"Price": "120"
|
||
},
|
||
{
|
||
"Procedure Code": "D1208",
|
||
"Description": "FL",
|
||
"Price": "90"
|
||
},
|
||
{
|
||
"Procedure Code": "D1351",
|
||
"Description": "sealant",
|
||
"Price": "80"
|
||
},
|
||
{
|
||
"Procedure Code": "D1999",
|
||
"Description": "",
|
||
"Price": "50"
|
||
},
|
||
{
|
||
"Procedure Code": "D2140",
|
||
"Description": "amalgam, one surface",
|
||
"Price": "150"
|
||
},
|
||
{
|
||
"Procedure Code": "D2150",
|
||
"Description": "amalgam, two surface",
|
||
"Price": "200"
|
||
},
|
||
{
|
||
"Procedure Code": "D2955",
|
||
"Description": "post renoval",
|
||
"Price": "350"
|
||
},
|
||
{
|
||
"Procedure Code": "D4910",
|
||
"Description": "perio maintains",
|
||
"Price": "250"
|
||
},
|
||
{
|
||
"Procedure Code": "D5510",
|
||
"Description": "Repair broken complete denture base (QUAD)",
|
||
"Price": "400"
|
||
},
|
||
{
|
||
"Procedure Code": "D6056",
|
||
"Description": "pre fab abut",
|
||
"Price": "750"
|
||
},
|
||
{
|
||
"Procedure Code": "D6057",
|
||
"Description": "custom abut",
|
||
"Price": "800"
|
||
},
|
||
{
|
||
"Procedure Code": "D6058",
|
||
"Description": "porcelain, implant crown, ceramic crown",
|
||
"Price": "1400"
|
||
},
|
||
{
|
||
"Procedure Code": "D6059",
|
||
"Description": "",
|
||
"Price": "1400"
|
||
},
|
||
{
|
||
"Procedure Code": "D6100",
|
||
"Description": "",
|
||
"Price": "320"
|
||
},
|
||
{
|
||
"Procedure Code": "D6110",
|
||
"Description": "implant",
|
||
"Price": "1600"
|
||
},
|
||
{
|
||
"Procedure Code": "D6242",
|
||
"Description": "noble metal. For united",
|
||
"Price": "1400"
|
||
},
|
||
{
|
||
"Procedure Code": "D6245",
|
||
"Description": "porcelain, not for united",
|
||
"Price": "1400"
|
||
},
|
||
{
|
||
"Procedure Code": "D7910",
|
||
"Description": "suture, small wound up to 5 mm",
|
||
"Price": "400"
|
||
},
|
||
{
|
||
"Procedure Code": "D7950",
|
||
"Description": "max",
|
||
"Price": "800"
|
||
},
|
||
{
|
||
"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": "D2931",
|
||
"Description": "Prefabricated stainless steel crown – permanent tooth",
|
||
"PriceLTEQ21": "199",
|
||
"PriceGT21": "171"
|
||
},
|
||
{
|
||
"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": "D2999",
|
||
"Description": "Unspecified restorative procedure, by report",
|
||
"PriceLTEQ21": "IC",
|
||
"PriceGT21": "IC"
|
||
},
|
||
{
|
||
"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": "D5520",
|
||
"Description": "Replace missing or broken teeth - complete denture (each tooth)",
|
||
"PriceLTEQ21": "89",
|
||
"PriceGT21": "77"
|
||
},
|
||
{
|
||
"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": "D6999",
|
||
"Description": "Fixed prosthodontic procedure",
|
||
"PriceLTEQ21": "IC",
|
||
"PriceGT21": "IC"
|
||
},
|
||
{
|
||
"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": "D7251",
|
||
"Description": "Coronectomy- intentional partial tooth removal, impacted teeth only",
|
||
"PriceLTEQ21": "173",
|
||
"PriceGT21": "134"
|
||
},
|
||
{
|
||
"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": "D7310",
|
||
"Description": "Alveoloplasty in conjunction with extractions-four or more teeth or tooth spaces, per quadrant",
|
||
"PriceLTEQ21": "163",
|
||
"PriceGT21": "142"
|
||
},
|
||
{
|
||
"Procedure Code": "D7311",
|
||
"Description": "Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant",
|
||
"PriceLTEQ21": "146",
|
||
"PriceGT21": "128"
|
||
},
|
||
{
|
||
"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": "D7999",
|
||
"Description": "Unspecified oral surgery procedure, by report",
|
||
"PriceLTEQ21": "IC",
|
||
"PriceGT21": "IC"
|
||
},
|
||
{
|
||
"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": "D8670",
|
||
"Description": "Periodic orthodontic treatment visit (Orthodontist only)",
|
||
"PriceLTEQ21": "288",
|
||
"PriceGT21": "215"
|
||
},
|
||
{
|
||
"Procedure Code": "D8680",
|
||
"Description": "Orthodontic retention (removal of appliances, construction and placement of retainer(s)) (Orthodontist only)",
|
||
"PriceLTEQ21": "102",
|
||
"PriceGT21": "85"
|
||
},
|
||
{
|
||
"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": "IC",
|
||
"PriceGT21": "IC"
|
||
},
|
||
{
|
||
"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": "D9450",
|
||
"Description": "Rural add-on encounter payment",
|
||
"PriceLTEQ21": "31",
|
||
"PriceGT21": "31"
|
||
},
|
||
{
|
||
"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"
|
||
},
|
||
{
|
||
"Procedure Code": "D9999",
|
||
"Description": "Unspecified adjunctive procedure, by report",
|
||
"PriceLTEQ21": "IC",
|
||
"PriceGT21": "IC"
|
||
}
|
||
]
|