Part 535 - STATE REIMBURSEMENT FOR PAYMENT TO DENTISTS

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Statutory Authority: 
Social Services Law, Sections 20, 34, 364, 368

Section 535.1 - Payment for dentists' services to hospitalized patients.

Section 535.1 Payment for dentists' services to hospitalized patients.

(Additional statutory authority: Social Services Law, Section 368-a)

(a) Expenditures by social services districts for their payments to dentists for services rendered to a hospitalized patient shall be subject to State reimbursement as follows:

(1) only if such services are determined to be coverable benefits under the provisions of Part 505 of this Subchapter, by the State Commissioner of Health or his designee; or

(2) when the dentist has the responsibility for the care of the patient; or

(3) when the dentist's services are rendered as a consultant, surgical assistant, or for a special service, at the request of the attending dentist or physician responsible for the care of the patient.

(b) State reimbursement, however, shall not be available for compensation paid to a dentist for the care of hospitalized patients when such compensation has been included as an element of costs reflected in a hospital rate approved by the State Director of the Budget pursuant to section 2807 of the Public Health Law.

 

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Section 535.2 - Definitions.

535.2 Definitions. (Additional statutory authority: Social Welfare Law, Section 368-a) When used in this Part, unless otherwise expressly stated or unless the context or subject matter requires a different interpretation, the terms hereinafter set forth shall be interpreted in accordance with the definitions herein provided.

(a) Reimbursement means State reimbursement.

(b) Maximum reimbursable allowance means that portion of the expenditures for any dental service or procedure which shall be subject to reimbursement.

(c) Dentist includes periodontist, endodontist and oral surgeon.

(d) Attending dentist means that dentist who is primarily and continuously responsible for the service or procedures rendered to a patient.

(e) Consultation means advice and counsel from an accredited specialist called in by the attending dentist in regard to the further handling of the case by the attending dentist.

(f) Referral shall mean the transfer of a patient from one dentist to another for definitive treatment.

(g) Anesthesia time means that time elapsing from the beginning of the administration of the anesthetic agent until the anesthetist is no longer in personal attendance.

(h) The notation T means one time unit for each 15 minutes of anesthesia time during in-hospital oral surgery.

(i) By report means that the maximum reimbursable allowance is determined on an individual basis in consideration of the nature, extent and need for the procedure or service, the time, skill and equipment necessary therefor, and such other factors as may be pertinent.

 

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Section 535.3 - State reimbursement.

535.3 State reimbursement. (Additional statutory authority: Social Welfare Law, Sections 365-b, 368-a) (a) State and local charges.

(1) State reimbursement for local charges shall be based on payments actually made, except that in no case shall reimbursement be available for amounts paid in excess of the maximum reimbursable allowance hereinafter prescribed.

(i) If a service or procedure, which is not listed in section 535.5 of this Part, is necessarily performed, reimbursement shall be based on the expenditures actually made therefor, in accordance with applicable rules of the board and regulations of the department.

(2) The full amount paid for dental care for State charges shall be eligible for reimbursement, provided that such payment is the same as that which would be made for local charges in similar circumstances.

(b) Reimbursement for payment of dental fees. (1) Payments for dental services under the medical assistance program shall be reimbursable by the State only when the services were rendered by a general or specialist practitioner of dentistry meeting the qualifications therefor as set forth in section 506.1 of the regulations of the department or when the services were provided in a dental clinic affiliated with State University of New York at Buffalo School of Dentistry, Columbia University School of Dental and Oral Surgery or New York University College of Dentistry and performed under the supervision of a general or specialist practitioner of dentistry meeting the qualifications therefor as set forth in section 506.1 of the regulations of the department.

(2) Reimbursement for consultation fee expenditures shall be available only when an examination is made by an accredited specialist within the scope of his specialty upon the request of the attending dentist who is treating the dental problem for which consultation is required. The attending dentist shall certify that he requested the consultation and that it was necessary for the further care of the patient.

(i) When the consultant dentist assumes the continuing care of the patient, any subsequent services rendered by him shall not be considered as consultation.

 

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Section 535.4 - Anesthesia.

535.4 Anesthesia. (a) Anesthesia services for in-hospital oral surgery.

(1) Expenditures by social services districts for anesthesia services for in-hospital oral surgery shall be reimbursable:

(i) if the anesthetic is administered personally by a qualified dentist or physician who remains in constant attendance during the procedure for the sole purpose of rendering such anesthesia service; and

(ii) if the Commissioner of Health or his designee determine such care, services and supplies are coverable benefits under the provisions of Part 505 of this Subchapter.

(2) The maximum reimbursable allowance for anesthesia services for in-hospital oral surgery shall be calculated by adding $5 for each 15 minutes of anesthesia time (T) plus 80 percent of the basic fee established in conjunction with the appropriate oral surgery procedure set forth in section 535.5.

(3) Total values for anesthesia services for in-hospital oral surgery shall include preoperative and postoperative visits, the administration of the anesthetic and the administration of fluids and/or blood incident to the anesthesia or surgery.

(b) Anesthesia services for office procedures. (1) The maximum reimbursable allowance for local anesthesia rendered in a dentist's office shall be included ii the fees established for the individual procedures.

(2) General anesthesia for in-office procedures may be administered by a qualified person other than the operating dentist and is reimbursable according to the provisions therefor in section 535.5.

 

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Section 535.5 - Maximum reimbursable dental fee schedules.

535.5 Maximum reimbursable dental fee schedules. (Additional statutory authority: Social Services Law, Section 363-a)

(a) Maximum reimbursable allowances for dental services except those dental services provided in certain dental clinics as set forth in subdivision (b) of this section and those provided in organized clinics in hospitals as set forth in sub-division (c) of this section. Fees for all services included in this subdivision shall be effective for care and services provided on and after April 1, 1974.

DIAGNOSTIC

Fee D011 Charting, history, oral examination

and completion of forms................... $5.00 D012 Periodic recall examination (oral checking) 5.00

Radiographic D021 Complete intraoral series of 14 periapical

films and 2 bite-wing films............... $15.00 D022 Intraoral periapical (first or single film) 2.00 D023 Each additional single film

(periapical or bite-wing)................. 1.00 D024 Occlusal view x-ray....................... 5.00 D025* Lateral jaw x-ray, each................... 10.00 D027 Four bite-wing x-ray films................ 6.00 D028 First or single bite-wing film

(use D023 for add. films)................. 2.00 D029* Antero-posterior x-ray of head and jaws... 10.00 D030* Cephalometric examination................. 10.00 D033 Panoramic (panography).................... 12.50 D034 Panoramic x-rays, supplemented by three (3)

or more additional intra-oral films

(periapical and/or bitewing) necessary to establish an accurate diagnosis, maximum payment........................... $15.00

(for panography with fewer than (3) supplemental films use Codes D023 and D033)

Supplementary Diagnostic Aids D047* Study models, where indicated............. $10.00

PREVENTIVE D111 Oral prophylaxis, child to age 12......... $6.90 D112 Over age 12............................ 8.80

Topical fluoride treatment following prophylaxis D121 4 treatments, sodium fluoride

only...................................... 17.50 D122 1 treatment, other than

sodium fluoride........................... 6.00

PERIODONTICS D212* Subgingival curettage and root planning--per

quadrant (at least 5 teeth)............... $10.00 D214 Incision and drainage of periodontal abscess 8.00 D215** Treatment for necrotizing ulcerative

gingivitis (Vincent's infection)

(incl. debridement and medication) per visit 10.00

ORAL SURGERY D311 Extraction, uncomplicated, permanent

tooth, includes local anesthesia.......... $7.50 D312** Extraction, uncomplicated, each

additional permanent tooth at same session, in same quadrant, includes local anesthesia.......................... 6.90 D313 Extraction, uncomplicated,

deciduous tooth, includes local anesthesia................................ 6.30 D314 Extraction, uncomplicated, each

additional deciduous tooth at same session, in same quadrant, includes local anesthesia.......................... 5.00 D320 Extraction--surgical removal of

erupted tooth, includes local anesthesia . 15.00 D321 Each additional adjacent tooth

surgically removed during the same session................................... 7.50 D322* Extraction--odontectomy, impacted

tooth, soft tissue, includes local anesthesia................................ 15.00 D323 partially covered by bone -

includes local anesthesia................. 25.00 D324* completely covered by bone -

includes local anesthesia................. 45.00 D325* Extraction, removal of residual

root covered by bone, includes local anesthesia................................ 15.00 D326* Repair--surgical exposure of

impacted tooth or unerupted tooth-for orthodontic reasons including ligation, includes local anesthesia....... 45.00 D331* Repair-Alveolectomy per jaw -

includes local anesthesia................. 25.00 D360 Fracture, maxilla, simple or

compound, no reduction.................... By Report D361 Fracture, maxilla, simple open reduction,

with wiring of teeth and/or local FOLLOW fixation UP DAYS 200.00 Anesthesia 90 16+T D362 Fracture, maxilla, simple closed

reduction, with wiring of teeth 120.00 Anesthesia 90 16+T D363 Fracture, mandible, simple open

reduction. with or without wiring of teeth 200.00 Anesthesia 90 16+T D364 Fracture, mandible, simple closed

reduction and wiring of teeth 120.00 Anesthesia 90 16+T D365 Fracture, maxilla, complicated,

open reduction, fixation by headcap, multiple surgical approaches, internal fixation, wiring teeth, etc By Report D369 Fracture, mandible, simple

or compound, no reduction By Report D373* Repair--Osteoplasty (mandible,

for prognathism or micrognathism), one or two stages 400.00 Anesthesia 90 20+T D374 Fracture, malar, simple or

compound, no reduction By Report D375 Closed reduction (incl.

towel clip technique) 20.00 Anesthesia 16+T D376 Depressed, open reduction 120.00

Anesthesia 60 16+T D377 Complicated, depressed, open

reduction with internal skeletal fixation and multiple surgical approaches 260.00 Anesthesia 90 20+T D378 Fracture, mandible, skeletal

pinning with external fixation 160.00 Anesthesia 90 16+T D384 Incision and drainage of abscess-Dento-alveolar 10.00 D385 Infra-orbital, palatal, peri-coronol,

sub-maxillary, sublinqual, submental, masseteric, floor of mouth, others except periodontal $15.00 ________________________________________________________________________

* Prior approval required except in emergency. ** Prior approval required in some cases (See regulations or guidelines)

Fee

ENDODONTICS

(Including radiographs but exclusive of restoration) D420 Vital pulpotomy $ 10.00 D431** Single root canal filling 50.00 D432** Double root canal filling 75.00 D439* Anterior tooth: root canal filling

with apicoectomy and/or root-end amalgam 75.00 D440* Apicoectomy (separate procedure) 35.00

OPERATIVE (RESTORATIVE) SERVICES

(Filling includes bases as necessary) D511 Silver amalgam--1 surface $6.30 D512 Silver amalgam--2 surface 11.30 D513 Silver amalgam--3 surface or more $17.50 D514 Silver amalgam--reinforcement pins--1st pin

(to be added to restoration cost) $5.00 D515 --each additional pin 3.00 D520 Silicate cement filling--maximum payment

two fillings per tooth 7.00 D531 Plastic Class III--maximum payment two

fillings per tooth 9.00 D532 Plastic Class IV--maximum payment two

fillings per tooth 12.00 D551* Cast gold--1 surface 35.00 D552* Cast gold--2 surfaces 45.00 D553* Cast gold--3 surfaces or more 60.00

CROWN AND BRIDGE D610* Acrylic jacket (quick cure) $30.00 D611* Acrylic or vinyl jacket crown 70.00 D614* Porcelain jacket crown 80.00 D617* Acrylic veneer jacket crown 75.00 D618* Porcelain veneer jacket crown 100.00 D619* Cast gold full crown 70.00 D620* Gold band crown with cast occlusal 60.00 D622* 3/4 cast gold crown 60.00 D624 Crowns, stainless steel--primary

or permanent tooth 20.00 D625* Pontics: Cast gold (sanitary) 40.00 D626* Steele's facing 50.00 D627* Tru-pontic type 50.00 D628* Plastic processed to gold 50.00 D629* Gold dowel and core for porcelain

or acrylic jacket crown 35.00 D642 Recementing crown 10.00 D643 Recementing fixed bridge 20.00 D651 Replacing facing (slot and tube) 15.00

PROSTHETICS D711* Full upper acrylic denture including

necessary adjustments $150.00 D712* Full lower acrylic denture including

necessary adjustments 150.00 D713* Immediate denture including chairside

relines--including necessary adjustments 165.00 D722* Partial acrylic denture, upper or

lower, including teeth and two clasps with rests 110.00 D727* Cast chrome partial--two clasps,

acrylic saddle 170.00 D728* Wrought lingual bar-2 wrought

clasps, acrylic saddle 120.00 D731* Each additional clasp with rest 22.00 D732* Each additional wrought clasp,

with rest 20.00 D743 Denture repair--no teeth 12.50 D744 Repair of denture base plus

replacing one tooth 16.30 D745 Replacing each additional tooth 6.30 D746 Replacing broken tooth -- no other

repair 10.00 D747 Add tooth to partial, replace

extracted tooth in acrylic 16.30 D748 Add tooth to partial, replacing

extracted tooth with welded loop 25.00 D749* Partial acrylic denture, upper

or lower, replacing one or two anterior teeth, no clasps

(Flipper or Stayplate)--Use 10745 for each additional tooth 75.00 D750 Replacing one arm of a clasp 17.50 D751 Replacing undamaged clasp

on partial 18.00 D752 Replacing broken clasp with

new clasp 30.00 D753* Rebasing upper or lower,

full denture 43.80 D754* Rebasing upper or lower partial 43.80 D757* Duplicating denture, full

or partial 75.00

ORTHODONTICS

Active treatment in private office: D853* 1st year including appliances 1/ $500.00 D854* 2nd year 375.00 D855* 3rd year $125.00

(Maximum cost for active treatment $1,000.00) D856* Retention not to exceed 12 visits

per year at $6.25 per visit, annual maximum payment 75.00 D857* Observation not to exceed 6 visits

per year at $6.25 per visit, annual maximum payment 37.50 1/ Billing for first year of care should be from date appliances are inserted. This is based on a fee of $187.50 for preparation and construction of appliance and $26.04 per month for 12 months of active treatment after the appliances are inserted, making a total fee of $500.00 for first year of care.

(See regulations or guidelines)

MISCELLANEOUS SERVICES D910 Palliative treatment of dental pain

(in office, during office hours) $5.00 D911 Home visits 2/, by dentist per

visit, regardless of number of patients seen (to be added to fee for service) 5.00 D913 Hospital Visit 3/, by dentist per,

visit, regardless of number of patients seen (to be added to fee for service) 5.00 D923 Anesthesia--general in office,

by qualified person other than operating dentist, 1st hour 10.00 each additional 30 minutes 5.00 D925 General Anesthesia for multiple

extractions in hospital

(basic fee) 15.00 basic fee plus each 15 minutes of anesthesia time 5.00 D940 Consultation by qualified

specialist 20.00 2/ The fee for a home visit represents the total extra charge permitted, and is not applicable to each patient seen at such visit. Payments at home call rates apply to services provided to persons in boarding homes nursing homes, convalescent homes, proprietary homes for adults, private homes for the aged, institutions for the blind, and places of residence used as an individual's home. 3/ The fee for a hospital visit is not applicable when covered by a specified number of follow-up days.

NON-SPECIALISTS Clinic Session D950 Three-hour session $35.00 D951 Each additional hour (per hour) 7.00

Shorter Clinic Session

(Less than 3 hours) D953 One-hour session 15.00 D954 Two-hour session 25.00

SPECIALISTS

Clinic Session D960 Three-hour session 50.00 D961 Each additional hour (per hour). 10.00

Shorter Clinic Session

(Less than 3 hours) D963 One-hour session 20.00 D964 Two-hour session 35.00

(b) Maximum reimbursable allowances for dental services rendered in dental clinics affiliated with State University of New York at Buffalo School of Dentistry,Columbia University School of Dental and Oral Surgery, and New York University College of Dentistry. Code Procedure Fee

DIAGNOSTIC DC011 Charting, history, oral

examination and completion of forms $3.00 DC012 Periodic recall examination

(oral checking) 3.00 RADIOGRAPHIC DC021 Complete intraoral series of 14

periapical films and 2 bite-wing films 7.50 DC022 First intraoral periapical

(single film) .50 DC023 Each additional single film .50 DC024 Occlusal view x-ray. 1.00 DC025 Lateral jaw x-ray each 2.00 DC027 Four bite-wing x-ray films 2.00 DC028 Single bite-wing film .50 DC029 Antero-posterior x-ray of

head and jaws 5.00 DC030 Cephalometric examination 5.00 DC033 Panoramic (panography) 10.00

SUPPLEMENTARY DIAGNOSTIC AIDS DC047 Study models, where indicated 5.00

PREVENTIVE DC111 Oral prophylaxis, child to age 12 2.00 DC112 Over age 12 3.00 DC120 Topical fluoride treatment following

prophylaxis DC121 4 treatments 10.00 DC122 1 treatment 3.00

PERIODONTICS DC212 Subgingival scaling and planning

per quadrant (at least 5 teeth) 5.00 DC214 Incision and drainage of

periodontal abscess 5.00 DC215 Treatment for rectitizing

ulcerative gingivitis (Vincent's infection) (incl. debridement and medication) per visit 5.00 DC216 Night guard or day guard

(bite guard) 15.00 DC217 Temporary splinting (wire ligation

or stainless steel bands) 10.00 DC218 Splint resin 15.00 DC219 Gingivectomy and/or gingivoplasty

(per quadrant) 20.00 DC220 Periodontal surgical flap

(per quadrant) 20.00 DC221 Periodontal surgical bone implant 20.00 ORAL SURGERY DC311 Extraction, removal of tooth,

uncomplicated, includes local anesthesia 2.00 DC312 Extraction--multiple removal of

teeth, per tooth, includes local anesthesia 2.00 DC321 Extraction--surgical removal of

erupted tooth, includes local anesthesia 3.00 DC322 Extraction--odontectomy, impacted

tooth, soft tissue, includes local anesthesia 10.00 DC323 partially covered by bone--includes

local anesthesia 15.00 DC324 completely covered by bone--includes

local anesthesia 25.00 DC325 Extraction--removal of residual root

covered by bone, includes local anesthesia 10.00 DC326 Repair--surgical exposure of

impacted tooth or unerupted tooth--for orthodontic reasons including ligation, includes local anesthesia 10.00 DC331 Repair--alveolectomy per jaw-

includes local anesthesia 10.00 DC360 Fracture, maxilla, simple or

compound, no reduction By report DC361 Fracture, maxilla, simple open

reduction, with wiring of teeth and/or local fixation 100.00 DC362 Fracture, maxilla, simple closed

reduction, with wiring of teeth 75.00 DC363 Fracture, mandible, simple open

reduction, with or without wiring o.100.00 DC364 Fracture, mandible, simple closed

reduction and wiring of teeth 75.00 DC365 Fracture, maxilla, complicated,

open reduction, fixation by head cap, multiple surgical approaches, internal fixation, wiring teeth, etc by report DC369 Fracture, mandible, simple or

compound, no reduction by report DC373 Repair--osteoplasty (mandible,

for prognathism or micrognathism), one or two stages $200.00 DC374 Fracture, malar, simple or compound,

no reduction by report DC375 Closed reduction (incl. towel

clip technique) 10.00 DC376 Depressed, open reduction 75.00 DC377 Complicated, depressed, open

reduction with internal skeletal fixation and multiple surgical approaches 130.00 DC378 Fracture, mandible, skeletal

pinning with external fixation 75.00 DC384 Incision and drainage of

abscess- dento-alveolar 7.00 DC385 Infra-orbital, palatal, peri-coronal,

submaxillary, sublingual, submental, masseteric, floor of mouth, others except periodontal 10.00 DC386 Biopsy 10.00 DC387 Tumor excision 25.00 DC388 Redundant tissue removal 25.00 DC389 Frenectomy 15.00 DC390 Cysts--soft tissue 10.00 DC391 Cysts--bone 25.00 DC392 Tuberosity reduction 10.00 DC393 Torus mandibularis removal 20.00 DC394 Torus palatinus removal 30.00

ENDODONTICS (including radiographs but exclusive of restoration) DC410 Pulp capping 3.00 DC420 Vital pulpotomy 5.00 DC431 Single root canal filling 30.00 DC432 Double root canal filling 40.00 DC439 Anterior tooth: root canal filling

with apicoectomy and/or root-end amalgam 40.00 DC440 Apicoectomy (separate procedure) 10.00 DC441 Molar (3 or more canals) 50.00

OPERATIVE (RESTORATIVE) SERVICES

(Fees for fillings include excavation and bases as necessary) DC511 Silver amalgam--1 surface 3.00 DC512 Silver amalgam--2 surface 5.00 DC513 Silver amalgam--3 surface or more 5.00 DC514 Silver amalgam reinforcement pins

-1st pin (to be added to restoration cost) 3.00 DC515 --each addition pin 2.00 DC520 Silicate cement filling 3.00 DC531 Plastic class III 3.00 DC532 Plastic class IV 3.00 DC551 Cast gold--1 surface 6.00 DC552 Cast gold--2 surface 10.00 DC553 Cast gold--3 surface 12.00 DC554 Gold foil 7.00 DC555 Inlays, porcelain 10.00

CROWN AND BRIDGE DC610 Acrylic jacket (quick cure) 10.00 DC611 Acrylic or vinyl jacket crown 25.00 DC614 Porcelain jacket crown 25.00 DC617 Acrylic veneer jacket crown 35.00 DC618 Porcelain veneer jacket crown 60.00 DC619 Cast gold full crown 35.00 DC620 Gold band crown with cast occlusal 30.00 DC622 3/4 Cast gold crown 30.00 DC624 Crowns, stainless steel--primary

or permanent tooth 10.00 DC625 Pontic: Cast gold (sanitary) 25.00 DC626 Steele's facing 30.00 DC627 Tru-pontic type 30.00 DC628 Plastic processed to gold 30.00 DC629 Gold dowel and core for porcelain

or acrylic jacket crown 10.00 DC642 Recementing crown 5.00 DC643 Recementing fixed bridge 10.00 DC651 Replacing facing (slot or tube) 10.00 DC658 Space maintainer 20.00

PROSTHETICS DC711 Full upper acrylic denture including

necessary adjustments 75.00 DC712 Full lower acrylic denture including

necessary adjustments 75.00 DC713 Immediate denture including

chairside relines--including necessary adjustments 80.00 DC722 Partial acrylic denture, upper

or lower, including teeth and 2 clasps with rests 50.00 DC727 Cast chrome partial--two clasps,

acrylic saddle (acrylic base) 115.00 DC728 Wrought lingual bar--2 wrought

clasps acrylic saddle 75.00 DC731 Each additional clasp with rest 10.00 DC732 Each additional wrought clasp 10.00 DC743 Denture repair--no teeth 7.00 DC744 Denture repair replacing

one tooth 9.00 DC745 Replacing each additional tooth 3.00 DC746 Replacing broken tooth--no other

repair 5.00 DC748 Add tooth to partial replacing

extracted tooth 15.00 DC751 Replacing undamaged clasp on

partial 10.00 DC752 Replacing broken clasp with

new clasp 25.00 DC753 Rebasing upper or lower, full

denture 25.00 DC754 Rebasing upper or lower, partial 25.00 DC757 Duplicating denture, full

or partial 40.00 MISCELLANEOUS SERVICES DC910 Palliative treatment of dental

pain (in clinic, during clinic hours) 3.00 DC923 Anesthesia--general in clinic,

by qualified person other than operating dentist, 1st hour 5.00 DC924 each additional 30 minutes 5.00 DC926 Temporomandibular joint--history

and clinical exam 5.00

(All injectables are to be reimbursed at cost.)

(c) Maximum reimbursable fees payable to qualified dentists for dental services provided on a per session basis in organized clinics of hospitals possessing valid operating certificates issued by the New York State Department of Health. Practitioners who receive compensation from the facility for providing health services shall be ineligible for additional payment. The fees listed below shall be prorated in accordance with the ratio of medical assistance recipients to the total number of patients seen during a clinic session. The fees listed below shall not apply to services provided in dental school clinics nor to care provided in independent, out-of-hospital facilities. The fees listed in this subdivision shall apply to services rendered on and after August 1, 1969.

Non-specialists Clinic session D950 Three-hour session $28.00 D951 Each additional hour, per hour 5.60

Shorter clinic session

(less than three hours) D953 One-hour session 12.00 D954 Two-hour session 20.00

Specialists

Clinic session D960 Three-hour session 40.00 D961 Each additional hour, per hour 8.00

Shorter clinic session

(less than three hours) D963 One-hour session 16.00 D964 Two-hour session 28.00

 

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