| Procedure Description | Reimb Amount | Waiting Period |
| Prohylaxis -Adult |
$29 |
No Waiting Period |
| Periodic Oral Exam |
$10 |
No Waiting Period |
| Limited Oral Exam |
$10 |
No Waiting Period |
| Intraoral-Periapical-First
Film |
$5 |
No Waiting Period |
| X-rays-Bitewing Four Films |
$15 |
No Waiting Period |
| X-rays-Bitewings Two Films |
$9 |
No Waiting Period |
| Extraction - Erupted Tooth |
$29 |
90 Days |
| Prohylaxis - Child |
$20 |
No Waiting Period |
| Topical Application
Flouride |
$8 |
No Waiting Period |
| Resin Based Composite -
One |
$28 |
90 Days |
| Limited Oral Exam-Problem |
$10 |
No Waiting Period |
| Intraoral - Periapical 0
Each Add Film |
$3 |
90 Days |
| X-Rays - Panoramic Film |
$29 |
No Waiting Period |
| Intraoral-Complete
Bitewings |
$36 |
No Waiting Period |
| Sealant - Per Tooth |
$13 |
90 Days |
| Periodontal Scaling &
Root |
$48 |
90 Days |
| Amalgam - Two Surfaces |
$30 |
90 Days |
| Resin Based Composite -
Two |
$36 |
90 Days |
| Amalgam - One Surface |
$22 |
90 Days |
| Resin Based Composite -
One |
$28 |
90 Days |
| Crown-Porcelain Fused to
Hi Noble |
$176 |
12 Month |
| Surgical Removal of
Erupted Tooth |
$49 |
90 Days |
| Core Buildup, Including
any Pins |
$38 |
12 Month |
| Periodontal Maintenance |
$31 |
90 Days |
| Resin Based Composite -
Two |
$36 |
90 Days |
| Topical Application of
Flouride w/cleaning |
$11 |
No Waiting Period |
| Resin Based Composite -
Three |
$46 |
90 Days |
| RC Ther-Molar Exc Final |
$231 |
90 Days |
| Amalgam - Three Surfaces
- Primary |
$36 |
90 Days |
| Analgesia, Anxiolysis,
Inhalation |
$13 |
90 Days |
| Resin Based Composite -
Three |
$46 |
90 Days |
| Full Mouth Debridement to
Enable |
$48 |
90 Days |
| Topical Application with
Flouride |
$25 |
No Waiting Period |
| Crown-Porcelain Fused to
Noble Metal |
$176 |
12 Month |
| Prefab Stainless Steel
Crown Primary |
$38 |
12 Month |
| RC Ther-Bicuspid Exc
Final Restoration |
$176 |
90 Days |
| Resin Composite 4+
Surfaces |
$56 |
90 Days |
| Pulp Cap Indirect |
$13 |
90 Days |
| Removal Impacted Tooth |
$121 |
90 Days |
| Prefabricated Post and
Core |
$53 |
12 Month |
| Root Canal Therapy |
$147 |
90 Days |
| Removal Impacted
Tooth-Partial Bony |
$89 |
90 Days |
| Recement Crown |
$13 |
12 Month |
| Initial Oral Exam |
$15 |
No Waiting Period |
| Crown - Porcelain Fused
to High |
$155 |
12 Month |
| Resin Based Composite -
Four+ Surfaces |
$56 |
90 Days |
| Palliative Treatment |
$18 |
No Waiting Period |
