Page 5 - Golden Dental Plans – HealthChoice Senior Dental Program

HealthChoice of Michigan Senior Covered Services and Co-Payment Schedule
Endodontics** (interior of tooth)
Member Co-pay
Anterior Root Canal Therapy . . . . . . . . . . . . . . . . . . . . . $250.00 Premolar Root Canal Therapy . . . . . . . . . . . . . . . . . . . . $285.00 Molar Root Canal Therapy . . . . . . . . . . . . . . . . . . . . . . . $350.00 Retreat of Previous RCT - anterior. . . . . . . . . . . . . . . . . $290.00 Retreat of Previous RCT - premolar. . . . . . . . . . . . . . . . $350.00
Repair of Prosthesis
Member Co-pay
Retreat of Previous RCT - molar . . Therapeutic Pulpotomy . . . . . . . . . Retrograde filling (per root) . . . . . . Apicoectomy - anterior . . . . . . . . . Apicoectomy - premolar (first root) Apicoectomy - molar (first root) . . . Apicoectomy (each addt'l. root) . . Pulp Cap (direct/indirect) . . . . . . . .
. . . . . . . . . . . . . . . . $410.00 . . . . . . . . . . . . . . . . . $40.00 . . . . . . . . . . . . . . . . . $50.00 . . . . . . . . . . . . . . . . $375.00 . . . . . . . . . . . . . . . . $350.00 . . . . . . . . . . . . . . . . $400.00 . . . . . . . . . . . . . . . . $150.00 . . . . . . . . . . . . . . . . . $15.00
. . . . . . . . . . $35.00 . . . . . . . . . . $80.00 . . . . . . . . . $105.00 . . . . . . . . . . $50.00 . . . . . . . . . $120.00 . . . . . . . . . $110.00 . . . . . . . . . $110.00 . . . . . . . . . $110.00 . . . . . . . . . $110.00 . . . . . . . . . $175.00 . . . . . . . . . $175.00 . . . . . . . . . $175.00
Member Co-pay
. . . . . . . . . . $25.00
. . . . . . . . . . $25.00 . . . . . . . . . . $50.00 . . . . . . . . . . $70.00 . . . . . . . . . $110.00 . . . . . . . . . $170.00
. . . . . . . . . $225.00 . . . . . . . . . . $95.00
. . . . . . . . . $200.00
Periodontics** (gums and supporting tissue)
Comprehensive Periodontal Evaluation . . . . . . Scaling due to Inflammation . . . . . . . . . . . . . . . Full Mouth Debridement . . . . . . . . . . . . . . . . . . Periodontal Maintenance . . . . . . . . . . . . . . . . . Perio Scaling/Root Planing (4 or more teeth) . . Perio Scaling/Root Planing (1-3 Teeth) . . . . . . . Site Specific Therapy (per tooth) . . . . . . . . . . . Gingivectomy/Gingivoplasty (>=4 or bounded) Gingivectomy/Gingivoplasty (<=3 or bounded) Gingival Flap Procedure (>=4 or bounded). . . . Gingival Flap Procedure (<=3 or bounded). . . . Osseous Surgery (>=4 or bounded) . . . . . . . . . Osseous Surgery (<=3 or bounded) . . . . . . . . . Occlusal Adjustment (limited) . . . . . . . . . . . . . .
Prosthodontic (removables)
Member Co-pay
. . . . . . . . $25.00 . . . . . . . . $20.00 . . . . . . . . $30.00 . . . . . . . . $35.00 . . . . . . . . $50.00 . . . . . . . . $45.00 . . . . . . . . $50.00 . . . . . . . $235.00 . . . . . . . $195.00 . . . . . . . $290.00 . . . . . . . $260.00 . . . . . . . $385.00 . . . . . . . $320.00 . . . . . . . . $30.00
Member Co-pay
. . . . . . . . . . $40.00 . . . . . . . . . . $35.00
CompleteUpperDenture .......................$350.00 Complete Lower Denture . . . . . . . . . . . . . . . . . . . . . . . . $350.00 ImmediateMaxillaryDenture(Upper) ..............$375.00 Immediate Mandibular Denture (Lower) . . . . . . . . . . . . . $375.00 Partial U/L Denture- cast metal framework . . . . . . . . . . $450.00 with resin bases (inc. regular clasps, rests & teeth) PartialDentureU/L(acrylicresinbase) .............$310.00 Tissueconditioning,maxillary .....................$40.00 Tissueconditioning,mandibular ...................$40.00 Adust complete denture - maxillary . . . . . . . . . . . . . . . . . $15.00 Adjust complete denture - mandibular. . . . . . . . . . . . . . . $15.00 Adjust partial denture - maxillary . . . . . . . . . . . . . . . . . . . $15.00 Adjustpartialdenture-mandibular .................$15.00 Interim Complete Denture Maxillary. . . . . . . . . . . . . . . . $165.00 InterimCompleteDentureMandibular ................$165.00
Orthodontics*** Lifetime Maximum
• $1,800.00 (up to age 19, comprehensive case only)
• $1,200.00 (Adult Member, Spouse, and dependent 19 and older)
. . . . . . . . . . $75.00
Repair Broken Complete Denture Base . . . . . . . . . . . . . . . . . . $60.00 Repair Resin Denture Base. . . . . . . . . . . . . . . . . . . . . . . . . . . . $60.00 Replace missing/broken tooth on denture/partial . . . . . . . . . . $35.00
Replace Broken Teeth - Per Tooth . . . . . . . . . . . . Repair Cast Framework . . . . . . . . . . . . . . . . . . . . Repair or replace broken clasp. . . . . . . . . . . . . . . Add tooth to existing partial denture . ......... Add clasp to existing partial denture . ......... Reline Complete Maxillary Denture Chairside . . . Reline Complete Mandibular Denture Chairside . Reline Maxillary Partial Denture Chairside . . . . . . Reline Mandibular Partial Denture Chairside . . . . Reline Complete Maxillary Denture Laboratory . . Reline Complete Mandibular Denture Laboratory . Reline Mandibular Partial Denture Laboratory . . .
Oral Surgery**
Extraction, Coronal remnants - primary tooth . . . Extraction, erupted tooth or exposed root (elevation and/or forceps removal) . . . . . . . . . . . . Surgical Removal Of Erupted Tooth . . . . . . . . . . . Removal Of Impacted Tooth-Soft Tissue . . . . . . . Removal Of Impacted Tooth-Partially Bony . . . . . Removal Of Impacted Tooth-Completely Bony . . Removal Of Impacted Tooth-Completely
Bony, with Unusual Surgical Complications. . . . . Surgical Removal of Residual Roots . . . . . . . . . . Surgical Exposure Of Impacted Or Unerupted Tooth For Ortho . . . . . . . . . . . . . . . . . . . . . . . . . . Alveoloplasty In Conjunction With Extractions
- Per Quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . .
Aveoloplasty in Conj. with Ext - 1-3 teeth . . . . . .
Aveoloplasty Not In Conjunction With Extraction
-Per Quadrant. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Alveoloplasty not in conjunction with extractions- one to three teeth or tooth spaces, per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . $70.00 Removal of Lateral Exostosis
(maxilla or mandible). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $140.00 Removal of torus palatinus. . . . . . . . . . . . . . . . . . . . . . . . . . . $140.00 Removal of torus mandibularis. . . . . . . . . . . . . . . . . . . . . . . . $140.00 Incision And Drainage Of Abscess-Intraoral
Tissue conditioning - mandibular s/b . . . . . . . . . . . . . . . . . . . . $40.00 Intravenous moderate sedation first 15 minutes . . . . . . . . . . . . . 50% Intravenous moderate sedation each additional
15 minutes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50%
Unclassified Treatment
Member Co-pay
Office Visit For Observation(During Regularly
Scheduled Hours)-No Other Service Performed . . . . . . . . . . . . . . . . $5.00 Treatment Of Complications(post-Surgical)-
Unusual Circumstances, By Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . $15.00