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September 17, 2024 11:57
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| export const PatientsFormData = { | |
| PatientInformation: { | |
| PatientName: "John Doe", | |
| DateOfBirth: "1980-05-15", | |
| SubscriberID: "SUB123456", | |
| SubscriberName: "John Doe", | |
| TodaysDate: "2023-10-01", | |
| DateOfService: "2023-10-01", | |
| ZipCode: "12345", | |
| InsuredRelation: "SELF", | |
| COB: "Standard", | |
| }, | |
| InsuranceInformation: { | |
| InsuranceProvider: "METLIFE", | |
| PlanType: "PPO", | |
| PlanStatus: true, | |
| GroupName: "Acme Group", | |
| GroupNumber: "GRP7890", | |
| EffectiveDate: "2023-01-01", | |
| PlanStartDate: "2023-01-01", | |
| PlanYear: "Fiscal", | |
| FiscalPlanMonth: "JAN", | |
| InOutOfNetwork: "IN", | |
| InsuranceCompanyPhoneNumber: "1800-555-1234", | |
| InsuranceBillingAddress: "123 Insurance St, Cityville, State 12345", | |
| PayorID: "PAYOR001", | |
| }, | |
| CoveragePercentages: { | |
| Diagnostic: { | |
| codes: ["D0140", "D0150", "D0120"], | |
| percentage: 100, | |
| }, | |
| Preventive: { | |
| codes: ["D1110", "D1120", "D1206", "D1208", "D1351", "D1353"], | |
| percentage: 100, | |
| }, | |
| Basic: { | |
| codes: ["D2330", "D2331", "D2332", "D2335"], | |
| percentage: 80, | |
| }, | |
| Major: { | |
| codes: ["D2740", "D2783"], | |
| percentage: 50, | |
| }, | |
| Endodontics: { | |
| codes: ["D3310", "D3320", "D3346", "D3347"], | |
| percentage: 80, | |
| }, | |
| Periodontics: { | |
| codes: ["D4910", "D4341", "D4342", "D4346"], | |
| percentage: 80, | |
| }, | |
| OralSurgery: { | |
| codes: ["D7111", "D7140", "D7210", "D7250"], | |
| percentage: 80, | |
| }, | |
| Orthodontics: { | |
| codes: ["D8090", "D8040", "D8070", "D8020"], | |
| percentage: 50, | |
| }, | |
| ProsthodonticsFixed: { | |
| codes: ["D6245", "D6740"], | |
| percentage: 50, | |
| }, | |
| AdjunctiveGeneral: { | |
| codes: ["D9110", "D9222", "D9223"], | |
| percentage: 80, | |
| }, | |
| TMJ: { | |
| codes: ["D9944", "D9951", "D9952"], | |
| percentage: 50, | |
| }, | |
| PartialUpperLowerArch: { | |
| codes: ["D5213", "D5214", "D5223", "D5224"], | |
| percentage: 50, | |
| }, | |
| FullDentureUpperLowerArch: { | |
| codes: ["D5110", "D5120", "D5130", "D5140"], | |
| percentage: 50, | |
| }, | |
| }, | |
| MaximumsAndDeductibles: { | |
| AnnualIndividualMaximum: 1500, | |
| AnnualIndividualMaximumUsed: 500, | |
| IndividualAnnualDeductible: 50, | |
| IndividualAnnualDeductibleUsed: 25, | |
| FamilyAnnualDeductible: 150, | |
| FamilyAnnualDeductibleUsed: 75, | |
| FamilyPlanMaximum: 4500, | |
| FamilyPlanMaximumUsed: 1500, | |
| RolloverAmount: 0, | |
| }, | |
| CommonFrequencies: { | |
| Exams: { | |
| code: "2/12", | |
| description: "Twice per 12 months", | |
| codes: ["D0120", "D0140", "D0150", "D0160", "D0180"], | |
| source: "D0120", | |
| }, | |
| Prophy: { | |
| code: "2/12", | |
| description: "Twice per 12 months", | |
| codes: ["D1110", "D1120"], | |
| source: "D1110", | |
| }, | |
| BitewingXrays: { | |
| code: "1/12", | |
| description: "Once per 12 months", | |
| codes: ["D0274", "D0272"], | |
| source: "D0274", | |
| }, | |
| PanoramicXray: { | |
| code: "1/36", | |
| description: "Once per 36 months", | |
| codes: ["D0330"], | |
| source: "D0330", | |
| }, | |
| FullMouthXrays: { | |
| code: "1/36", | |
| description: "Once per 36 months", | |
| codes: ["D0210"], | |
| source: "D0210", | |
| }, | |
| Fluoride: { | |
| code: "2/12", | |
| description: "Twice per 12 months", | |
| codes: ["D1206", "D1208"], | |
| source: "D1206", | |
| }, | |
| Sealants: { | |
| code: "1/36", | |
| description: "Once per 36 months", | |
| codes: ["D1351", "D1353"], | |
| source: "D1351", | |
| }, | |
| ScalingAndRootPlaning: { | |
| code: "1/24", | |
| description: "Once per 24 months", | |
| codes: ["D4341", "D4342"], | |
| source: "D4341", | |
| }, | |
| PeriodontalMaintenance: { | |
| code: "4/12", | |
| description: "Four times per 12 months", | |
| codes: ["D4910"], | |
| source: "D4910", | |
| }, | |
| FullDebridement: { | |
| code: "1/LT", | |
| description: "Once per lifetime", | |
| codes: ["D4355", "D4346"], | |
| source: "D4355", | |
| }, | |
| Crowns: { | |
| code: "1/60", | |
| description: "Once per 60 months", | |
| codes: [ | |
| "D2740", | |
| "D2750", | |
| "D2751", | |
| "D2752", | |
| "D2780", | |
| "D2781", | |
| "D2782", | |
| "D2783", | |
| "D2790", | |
| "D2791", | |
| "D2792", | |
| ], | |
| source: "D2740", | |
| }, | |
| Dentures: { | |
| code: "1/84", | |
| description: "Once per 84 months", | |
| codes: ["D5110", "D5120"], | |
| source: "D5110", | |
| }, | |
| Fillings: { | |
| code: "1/24", | |
| description: "Once per 24 months", | |
| codes: [ | |
| "D2330", | |
| "D2331", | |
| "D2332", | |
| "D2335", | |
| "D2391", | |
| "D2392", | |
| "D2393", | |
| "D2394", | |
| ], | |
| source: "D2330", | |
| }, | |
| }, | |
| CommonAgeLimitations: { | |
| Sealants: { | |
| code: "U16", | |
| description: "Up to age 16", | |
| }, | |
| Fluorides: { | |
| code: "U14", | |
| description: "Up to age 14", | |
| }, | |
| }, | |
| OrthodonticInformation: { | |
| AgeLimit: { | |
| code: "U18", | |
| description: "Under 18 years old", | |
| }, | |
| LifetimeMaximum: 2000, | |
| OrthoIndividualDeductibleAmount: 0, | |
| OrthoIndividualDeductibleAmountUsed: 0, | |
| MaximumAnnualIndividualOrthoBenefitAmount: 1000, | |
| OrthoPaymentCycle: "MONTHLY", | |
| SeparateOrthoMax: true, | |
| SeparateOrthoBenefit: true, | |
| }, | |
| CommonDowngrades: { | |
| PosteriorComposites: [ | |
| { | |
| from: { | |
| code: "D2391", | |
| procedure: "Posterior Composites", | |
| }, | |
| to: { | |
| code: "D2140", | |
| type: "Substitute", | |
| }, | |
| }, | |
| { | |
| from: { | |
| code: "D2392", | |
| procedure: "Posterior Composites", | |
| }, | |
| to: { | |
| code: "D2150", | |
| type: "Substitute", | |
| }, | |
| }, | |
| { | |
| from: { | |
| code: "D2393", | |
| procedure: "Posterior Composites", | |
| }, | |
| to: { | |
| code: "D2160", | |
| type: "Substitute", | |
| }, | |
| }, | |
| { | |
| from: { | |
| code: "D2394", | |
| procedure: "Posterior Composites", | |
| }, | |
| to: { | |
| code: "D2161", | |
| type: "Substitute", | |
| }, | |
| }, | |
| ], | |
| AnteriorComposites: [ | |
| { | |
| from: { | |
| code: "D2330", | |
| procedure: "Anterior Composites", | |
| }, | |
| to: { | |
| code: "D2140", | |
| type: "Substitute", | |
| }, | |
| }, | |
| { | |
| from: { | |
| code: "D2331", | |
| procedure: "Anterior Composites", | |
| }, | |
| to: { | |
| code: "D2150", | |
| type: "Substitute", | |
| }, | |
| }, | |
| { | |
| from: { | |
| code: "D2332", | |
| procedure: "Anterior Composites", | |
| }, | |
| to: { | |
| code: "D2160", | |
| type: "Substitute", | |
| }, | |
| }, | |
| { | |
| from: { | |
| code: "D2335", | |
| procedure: "Anterior Composites", | |
| }, | |
| to: { | |
| code: "D2161", | |
| type: "Substitute", | |
| }, | |
| }, | |
| ], | |
| Crowns: [ | |
| { | |
| from: { | |
| code: "D2740", | |
| procedure: "Crowns", | |
| }, | |
| to: { | |
| code: "D2750", | |
| type: "Substitute", | |
| }, | |
| }, | |
| ], | |
| ImplantServices: [ | |
| { | |
| from: { | |
| code: "D6010", | |
| procedure: "Implant Services", | |
| }, | |
| to: { | |
| code: "D5211", | |
| type: "Alternate Benefit", | |
| }, | |
| }, | |
| { | |
| from: { | |
| code: "D6011", | |
| procedure: "Implant Services", | |
| }, | |
| to: { | |
| code: "D5212", | |
| type: "Alternate Benefit", | |
| }, | |
| }, | |
| { | |
| from: { | |
| code: "D6012", | |
| procedure: "Implant Services", | |
| }, | |
| to: { | |
| code: "D5213", | |
| type: "Alternate Benefit", | |
| }, | |
| }, | |
| { | |
| from: { | |
| code: "D6013", | |
| procedure: "Implant Services", | |
| }, | |
| to: { | |
| code: "D5214", | |
| type: "Alternate Benefit", | |
| }, | |
| }, | |
| ], | |
| RetainerCrown: [ | |
| { | |
| from: { | |
| code: "D6740", | |
| procedure: "Retainer Crown", | |
| }, | |
| to: { | |
| code: "D6750", | |
| type: "Substitute", | |
| }, | |
| }, | |
| ], | |
| Pontic: [ | |
| { | |
| from: { | |
| code: "D6245", | |
| procedure: "Pontic", | |
| }, | |
| to: { | |
| code: "D6240", | |
| type: "Substitute", | |
| }, | |
| }, | |
| ], | |
| }, | |
| ServiceHistory: [ | |
| { | |
| Category: "Exams History", | |
| Services: [ | |
| { | |
| CDTCode: "D0120", | |
| FriendlyName: "Periodic Oral Evaluation", | |
| AllServiceDates: ["2023-06-15", "2023-01-10", "2022-07-22"], | |
| LastServiceDate: "2023-06-15", | |
| ToothArchSpecific: "No", | |
| }, | |
| { | |
| CDTCode: "D0140", | |
| FriendlyName: "Limited Oral Evaluation", | |
| AllServiceDates: ["2023-04-10"], | |
| LastServiceDate: "2023-06-16", | |
| ToothArchSpecific: "No", | |
| }, | |
| { | |
| CDTCode: "D0150", | |
| FriendlyName: "Comprehensive Oral Evaluation", | |
| AllServiceDates: ["2023-01-05"], | |
| LastServiceDate: "2023-06-17", | |
| ToothArchSpecific: "No", | |
| }, | |
| ], | |
| }, | |
| { | |
| Category: "FMX History", | |
| Services: [ | |
| { | |
| CDTCode: "D0210", | |
| FriendlyName: "Full Mouth X-ray Series", | |
| AllServiceDates: ["2022-01-20"], | |
| LastServiceDate: "2023-06-18", | |
| ToothArchSpecific: "No", | |
| }, | |
| ], | |
| }, | |
| { | |
| Category: "Pano History", | |
| Services: [ | |
| { | |
| CDTCode: "D0330", | |
| FriendlyName: "Panoramic X-ray", | |
| AllServiceDates: ["2022-01-20"], | |
| LastServiceDate: "2023-06-19", | |
| ToothArchSpecific: "No", | |
| }, | |
| ], | |
| }, | |
| { | |
| Category: "Prophy History", | |
| Services: [ | |
| { | |
| CDTCode: "D1110", | |
| FriendlyName: "Adult Prophylaxis", | |
| AllServiceDates: ["2023-06-15", "2022-12-20"], | |
| LastServiceDate: "2023-06-20", | |
| ToothArchSpecific: "No", | |
| }, | |
| { | |
| CDTCode: "D1120", | |
| FriendlyName: "Child Prophylaxis", | |
| AllServiceDates: ["2023-06-15", "2022-12-20"], | |
| LastServiceDate: "2023-06-21", | |
| ToothArchSpecific: "No", | |
| }, | |
| ], | |
| }, | |
| { | |
| Category: "Perio Maintenance History", | |
| Services: [ | |
| { | |
| CDTCode: "D4910", | |
| FriendlyName: "Periodontal Maintenance", | |
| AllServiceDates: ["2023-05-01", "2023-02-01"], | |
| LastServiceDate: "2023-06-22", | |
| ToothArchSpecific: "No", | |
| }, | |
| ], | |
| }, | |
| { | |
| Category: "SRP History", | |
| Services: [ | |
| { | |
| CDTCode: "D4341", | |
| FriendlyName: "Scaling and Root Planing, 4+ teeth", | |
| AllServiceDates: [ | |
| { | |
| Date: "2023-03-10", | |
| Quadrant: "UR", | |
| }, | |
| ], | |
| LastServiceDate: "2023-06-23", | |
| ToothArchSpecific: "Yes", | |
| }, | |
| { | |
| CDTCode: "D4342", | |
| FriendlyName: "Scaling and Root Planing, 1-3 teeth", | |
| AllServiceDates: [ | |
| { | |
| Date: "2023-03-10", | |
| Quadrant: "LR", | |
| }, | |
| ], | |
| LastServiceDate: "2023-06-24", | |
| ToothArchSpecific: "Yes", | |
| }, | |
| ], | |
| }, | |
| { | |
| Category: "Bitewing History", | |
| Services: [ | |
| { | |
| CDTCode: "D0274", | |
| FriendlyName: "Bitewing X-rays - Four Films", | |
| AllServiceDates: ["2023-06-15"], | |
| LastServiceDate: "2023-06-25", | |
| ToothArchSpecific: "No", | |
| }, | |
| ], | |
| }, | |
| { | |
| Category: "Crown History", | |
| Services: [ | |
| { | |
| CDTCode: "D2740", | |
| FriendlyName: "Crown - Porcelain/Ceramic", | |
| AllServiceDates: [ | |
| { | |
| Date: "2022-08-12", | |
| ToothNumber: "14", | |
| }, | |
| ], | |
| LastServiceDate: "2023-06-26", | |
| ToothArchSpecific: "Yes", | |
| }, | |
| ], | |
| }, | |
| { | |
| Category: "Filling History", | |
| Services: [ | |
| { | |
| CDTCode: "D2391", | |
| FriendlyName: "Resin-Based Composite - One Surface, Posterior", | |
| AllServiceDates: [ | |
| { | |
| Date: "2023-02-18", | |
| ToothNumber: "19", | |
| }, | |
| { | |
| Date: "2022-09-05", | |
| ToothNumber: "30", | |
| }, | |
| ], | |
| LastServiceDate: "2023-06-27", | |
| ToothArchSpecific: "Yes", | |
| }, | |
| ], | |
| }, | |
| { | |
| Category: "Implant History", | |
| Services: [ | |
| { | |
| CDTCode: "D6010", | |
| FriendlyName: "Surgical Placement of Implant Body", | |
| AllServiceDates: [ | |
| { | |
| Date: "2021-07-22", | |
| ToothNumber: "3", | |
| }, | |
| ], | |
| LastServiceDate: "2023-06-28", | |
| ToothArchSpecific: "Yes", | |
| }, | |
| ], | |
| }, | |
| { | |
| Category: "Fluoride History", | |
| Services: [ | |
| { | |
| CDTCode: "D1206", | |
| FriendlyName: "Topical Fluoride Varnish", | |
| AllServiceDates: ["2023-06-15", "2022-12-20"], | |
| LastServiceDate: "2023-06-29", | |
| ToothArchSpecific: "No", | |
| }, | |
| ], | |
| }, | |
| { | |
| Category: "Occlusal Guard History", | |
| Services: [ | |
| { | |
| CDTCode: "D9944", | |
| FriendlyName: "Occlusal Guard - Hard Appliance, Full Arch", | |
| AllServiceDates: [ | |
| { | |
| Date: "2022-11-30", | |
| Arch: "Upper", | |
| }, | |
| ], | |
| LastServiceDate: "2023-06-30", | |
| ToothArchSpecific: "Yes", | |
| }, | |
| ], | |
| }, | |
| { | |
| Category: "Sealant History", | |
| Services: [ | |
| { | |
| CDTCode: "D1351", | |
| FriendlyName: "Dental Sealant", | |
| AllServiceDates: [ | |
| { | |
| Date: "2022-03-05", | |
| ToothNumber: "3", | |
| }, | |
| { | |
| Date: "2022-03-06", | |
| ToothNumber: "14", | |
| }, | |
| { | |
| Date: "2022-03-07", | |
| ToothNumber: "19", | |
| }, | |
| { | |
| Date: "2022-03-08", | |
| ToothNumber: "30", | |
| }, | |
| ], | |
| LastServiceDate: "2023-07-01", | |
| ToothArchSpecific: "Yes", | |
| }, | |
| ], | |
| }, | |
| ], | |
| }; |
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