{"reporting_entity_name": "GQO_PPO","reporting_entity_type": "GQO_Risk Assuming Non Licensed Insurer","last_updated_on": "2026-10-07","version": "2.0","provider_references": [ {"provider_group_id":137083129,"network_name":[],"provider_groups":[{"npi":[1134499684,1265966444,1619284536,1972147239],"tin":{"type":"ein","value":"452608984","business_name":"Childrens Surgery Center of Malvern LLC"}}]} ], "in_network" : [ {"negotiation_arrangement":"ffs","name":"Dental prophylaxis adult","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D1110","description":"Dental prophylaxis adult","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Topical fluoride varnish","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D1206","description":"Topical fluoride varnish","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Space maintainer fxd unilat","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D1510","description":"Space maintainer fxd unilat","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Dental surgery procedure","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"41899","description":"Dental surgery procedure","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Dental sealant per tooth","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D1351","description":"Dental sealant per tooth","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Dental prophylaxis child","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D1120","description":"Dental prophylaxis child","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Amalgam one surface permanen","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2140","description":"Amalgam one surface permanen","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Fixed bilat space maintainer","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D1515","description":"Fixed bilat space maintainer","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Amalgam three surfaces perma","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2160","description":"Amalgam three surfaces perma","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Amalgam 4 or > surfaces perm","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2161","description":"Amalgam 4 or > surfaces perm","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Resin one surface-anterior","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2330","description":"Resin one surface-anterior","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Resin two surfaces-anterior","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2331","description":"Resin two surfaces-anterior","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Resin three surfaces-anterio","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2332","description":"Resin three surfaces-anterio","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Amalgam two surfaces permane","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2150","description":"Amalgam two surfaces permane","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Post 1 srfc resinbased cmpst","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2391","description":"Post 1 srfc resinbased cmpst","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Resin-based composite - four or more surfaces (anterior)","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2335","description":"Resin-based composite - four or more surfaces (anterior)","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Post 2 srfc resinbased cmpst","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2392","description":"Post 2 srfc resinbased cmpst","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Post >=4srfc resinbase cmpst","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2394","description":"Post >=4srfc resinbase cmpst","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Post 3 srfc resinbased cmpst","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2393","description":"Post 3 srfc resinbased cmpst","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Dental onlay porcelin 2 surf","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2642","description":"Dental onlay porcelin 2 surf","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Dental onlay porc 4/more sur","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2644","description":"Dental onlay porc 4/more sur","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Dental onlay porc 3/more sur","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2630","description":"Dental onlay porc 3/more sur","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Inlay porcelain/ceramic 2 su","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2620","description":"Inlay porcelain/ceramic 2 su","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Inlay composite/resin one su","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2650","description":"Inlay composite/resin one su","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Dental onlay porcelin 3 surf","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2643","description":"Dental onlay porcelin 3 surf","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Inlay composite/resin two su","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2651","description":"Inlay composite/resin two su","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Dental inlay resin 3/mre sur","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2652","description":"Dental inlay resin 3/mre sur","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Dental onlay resin 3 surface","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2663","description":"Dental onlay resin 3 surface","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Dental onlay resin 2 surface","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2662","description":"Dental onlay resin 2 surface","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Dental onlay resin 4/mre sur","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2664","description":"Dental onlay resin 4/mre sur","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Crown resin w/ base metal","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2721","description":"Crown resin w/ base metal","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Crown 3/4 resin-based compos","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2712","description":"Crown 3/4 resin-based compos","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Crown resin-based indirect","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2710","description":"Crown resin-based indirect","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Crown resin w/ high noble me","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2720","description":"Crown resin w/ high noble me","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Crown porcelain fused base m","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2751","description":"Crown porcelain fused base m","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Crown resin w/ noble metal","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2722","description":"Crown resin w/ noble metal","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Crown porcelain/ceramic subs","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2740","description":"Crown porcelain/ceramic subs","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Crown porcelain w/ h noble m","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2750","description":"Crown porcelain w/ h noble m","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Prefab stnlss steel crwn pri","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2930","description":"Prefab stnlss steel crwn pri","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Crown porcelain w/ noble met","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2752","description":"Crown porcelain w/ noble met","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Prefab stnlss steel crown pe","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2931","description":"Prefab stnlss steel crown pe","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Prefab porc/ceram crown pri","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2929","description":"Prefab porc/ceram crown pri","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Prefab stainless steel crown","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2933","description":"Prefab stainless steel crown","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Prefab steel crown primary","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2934","description":"Prefab steel crown primary","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Prefab post/core + crown","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D2954","description":"Prefab post/core + crown","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Pulp cap direct","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D3110","description":"Pulp cap direct","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Pulp cap indirect","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D3120","description":"Pulp cap indirect","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Therapeutic pulpotomy","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D3220","description":"Therapeutic pulpotomy","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Gross pulpal debridement","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D3221","description":"Gross pulpal debridement","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Pulpal therapy anterior prim","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D3230","description":"Pulpal therapy anterior prim","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Pulpal therapy posterior pri","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D3240","description":"Pulpal therapy posterior pri","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Anterior","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D3310","description":"Anterior","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Root canal therapy 3 canals","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D3330","description":"Root canal therapy 3 canals","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Bio mtrls to aid soft/os reg","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D4265","description":"Bio mtrls to aid soft/os reg","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Subepithelial tissue graft","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D4273","description":"Subepithelial tissue graft","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Root canal therapy 2 canals","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D3320","description":"Root canal therapy 2 canals","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Periodontal scaling & root","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D4341","description":"Periodontal scaling & root","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Custom abutment","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D6057","description":"Custom abutment","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Implant supported crown","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D6065","description":"Implant supported crown","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Full mouth debridement","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D4355","description":"Full mouth debridement","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"remove erupted tooth","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D7210","description":"remove erupted tooth","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Extraction erupted tooth/exr","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D7140","description":"Extraction erupted tooth/exr","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Impact tooth remov part bony","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D7230","description":"Impact tooth remov part bony","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Impact tooth remov comp bony","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D7240","description":"Impact tooth remov comp bony","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Excision hyperplastic tissue","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D7970","description":"Excision hyperplastic tissue","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Dental house call","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D9410","description":"Dental house call","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Impact tooth rem bony w/comp","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D7241","description":"Impact tooth rem bony w/comp","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}, {"negotiation_arrangement":"ffs","name":"Deep sedation/general anesthesia-first 30 minutes","billing_code_type":"CDT","billing_code_type_version":"2024","billing_code":"D9220","description":"Deep sedation/general anesthesia-first 30 minutes","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":3092.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[137083129]}]}]}