Page 4 - Golden Dental Plans – HealthChoice Senior Dental Program
P. 4
HealthChoice of Michigan Senior Covered Services and Co-Payment Schedule
Diagnostic and Preventive*
Member Co-pay
Office Visit (regular hours) . . . . . . . . . . . . . . . . . . . . . . . . . $5.00 Periodic Oral Evaluation. . . . . . . . . . . . . . . . . . . . . . . No Charge Comprehensive Oral Evaluation. . . . . . . . . . . . . . . . . No Charge Prediagnostic Test . . . . . . . . . . . . . . . . . . . . . . . . . . . No Charge Prophylaxis/Routine Cleaning - Adult**** . . . . . . . . . . No Charge Prophylaxis/Routine Cleaning - Child . . . . . . . . . . . . No Charge Oral Hygiene Instructions. . . . . . . . . . . . . . . . . . . . . . No Charge Local Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Charge Fluoride Treatment - Child . . . . . . . . . . . . . . . . . . . . No Charge Fluoride Treatment - Adult . . . . . . . . . . . . . . . . . . . . . . . . $15.00 Sealants (per tooth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $9.00
Restorative (fillings)
Composite Filling - One Surface (Anterior) Composite Filling - Two Surfaces (Anterior) Composite Filling - Three Surfaces (Anterior) Comp Filling-Four or More Surfaces (Anterior) Composite Filling - One Surface (Posterior) Composite Filling - Two Surface (Posterior) Composite Filling - Three Surface (Posterior) Composite Filling-Four Surfaces (Posterior)
Space Maintainer
Space Maintainer - Fixed - Unilateral . . . . . . . Space Maintainer - Fixed - Bilateral . . . . . . . . Space Maintainer - Removable - Unilateral. . . Space Maintainer - Removable - Bilateral. . . .
Re-cementation of Space Maintainer . . . . . . . Occlusal guard (night guard) . . . . . . . . . . . . . .
Crown and Bridge***
. . . .
. .
Member Co-pay
$20.00 $35.00 $50.00 $65.00 $35.00 $50.00 $65.00 $75.00
. . . . . . . $100.00 . . . . . . . $130.00 . . . . . . . $130.00 . . . . . . . $145.00
. . . . . . . . $15.00 . . . . . . . $200.00
Member Co-pay
X-Ray Coverage
Periapical - First Film . . . . . . . . . . . . . . . . . Periapical - Each Additional Film. . . . . . . . Intraoral - Occlusal Film. . . . . . . . . . . . . . . Bitewing - Single Film . . . . . . . . . . . . . . . . Bitewings - Two Films . . . . . . . . . . . . . . . . Bitewings - Three Films . . . . . . . . . . . . . . . Bitewings - Four Films . . . . . . . . . . . . . . . .
Member Co-pay
. . . . . . . . No Charge . . . . . . . . No Charge . . . . . . . . No Charge . . . . . . . . No Charge . . . . . . . . No Charge . . . . . . . . No Charge . . . . . . . . No Charge
Full cast predominantly base metal (per unit) . .
Crown - porcelain fused to pred. base metal . .
Porcelain fused to pred. base metal (per unit). .
3/4 past predominantly base metal (per unit) . . Crown-3/4castnoblemetal ......................$340.00 Crown - full cast high noble metal. . . . . . . . . . . . . . . . . . $340.00 Castnoblemetal(perunit)........................$340.00 Crownsemipreciousfullcast.....................$340.00 Pontic-castnoblemetal.........................$340.00 Prefabricated stainless steel-resin crown . . . . . . . . . . . . $110.00 Crown -prefab. stainless steel - perm. tooth. . . . . . . . . . $110.00 Crown-prefabricatedresincrown .................$110.00 Crown - prefab. stainless steel w/resin window . . . . . . . $110.00 Crown - full cast predominantly base metal . . . . . . . . . . $320.00 Porcelain -
predominantly base metal (per unit) . . . . . . . . . . . . . . . . . . . $350.00 Crown -
porcelain fused to predominantly base metal . . . . . . . . . $350.00 Porcelain fused to noble metal (per unit). . . . . . . . . . . . . $365.00 Crown-porcelainfusedtonoblemetal .............$365.00 Crown -
3/4 Cast predominantly base metal (per unit) . . . . . . . . . $295.00 Crown-3/4castnoblemetal ......................$340.00 Crown full cast noble metal . . . . . . . . . . . . . . . . . . . . . . . $340.00 Resin-based composite cown - anterior. . . . . . . . . . . . . $210.00 Provisionalcrown ..............................$100.00 Castpost&core ...............................$120.00 Prefabricatedpost&core ........................$110.00 Prefabricatedpost&core(bridge)..................$110.00
Adjunctive Services
Limited Oral Evaluation - Problem Focused . . . . . Intraoral - Complete Series . . . . . . . . . . . . . . Panoramic Film . . . . . . . . . . . . . . . . . . . . . . . Palliative (Emergency) Treatment . . . . . . . . . . Office Visit (after hours) . . . . . . . . . . . . . . . . . Office Visit (Reg. hours) . . . . . . . . . . . . . . . . . Recement inlay, onlay or partial cov. Rest . . . Recement Crown . . . . . . . . . . . . . . . . . . . . . . Recement cast or prefab. post and core . . . . Recement Bridge (fixed partial denture). . . . . Consultation (2nd Opinion). . . . . . . . . . . . . . . Sedative Filling . . . . . . . . . . . . . . . . . . . . . . . . Core Buildup (Including Any Pins) . . . . . . . . . Core Buildup for Bridge/Ret. (incl. any pins) . Diagnostic casts (each) . . . . . . . . . . . . . . . . .
Restorative (fillings)
Member Co-pay
. . . . . . No Charge . . . . . . No Charge . . . . . . No Charge . . . . . . . . . $20.00 . . . . . . . . . $55.00 . . . . . . . . . $20.00 . . . . . . . . . $10.00 . . . . . . . . . $10.00 . . . . . . . . . $20.00 . . . . . . . . . $20.00 . . . . . . . . . $48.00 . . . . . . . . . $15.00 . . . . . . . . . $85.00 . . . . . . . . . $85.00 . . . . . . . . . $20.00
Member Co-pay
. . . . . . . . . $15.00 . . . . . . . . . $20.00 . . . . . . . . . $30.00 . . . . . . . . . $45.00
. . . . . . . $325.00 . . . . . . . $325.00 . . . . . . . $340.00 . . . . . . . $295.00
Amalgam Filling - One Surface
Amalgam Filling - Two Surfaces
Amalgam Filling - Three Surfaces . . . . . . . . . Amalgam Filling - Four or More Surfaces . ..
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