Page 3 - Golden Health Choice Small Business

HealthChoice of Michigan Small Business Covered Services and Co-Payment Schedule
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 Sealants (per tooth). . . . . . . . . . . . . . . . . . . . . $12.00
X-Ray Coverage
Member Co-pay
Periapical - First Film . . . . . . . . . . . . . . . No Charge Periapical - Each Additional Film. . . . . . . . . . . $2.00 Intraoral - Occlusal Film . . . . . . . . . . . . . No Charge Bitewing - Single Film . . . . . . . . . . . . . . . No Charge Bitewings - Two Films . . . . . . . . . . . . . . . . . . . $8.00 Bitewings - Three Films. . . . . . . . . . . . . . . . . $10.00 Bitewings - Four Films. . . . . . . . . . . . . . . . . . $12.00
Adjunctive Services
Member Co-pay
Member Co-pay
Amalgam Filling - One Surface. . . . . . . . . . . . . . . $21.00 Amalgam Filling - Two Surfaces . . . . . . . . . . . . . $28.00 Amalgam Filling - Three Surfaces . . . . . . . . . . . . $35.00 Amalgam Filling - Four or More Surfaces. . . . . . . $45.00 Composite Filling - One Surface (Anterior). . . . . . $29.00 Composite Filling - Two Surfaces (Anterior) . . . . . $39.00 Composite Filling - Three Surfaces (Anterior). . . . $46.00 Comp Filling-Four or More Surfaces (Anterior) . . $62.00
Limited Oral Evaluation - Problem Focused Intraoral - Complete Series . . . . . . . . . . . . . Panoramic Film . . . . . . . . . . . . . . . . . . . . . . . Palliative (Emergency) Treatment . . . . . . . . . (minor-reg. hrs.)
Office Visit (after hours). . . . . . . . . . . . . . . . . Recement inlay, onlay or partial cov. Rest . . Recement Crown . . . . . . . . . . . . . . . . . . . . . Recement cast or prefab. post and core . . . Recement Bridge (fixed partial denture) . . . . Sedative Filling . . . . . . . . . . . . . . . . . . . . . . . Core Buildup (Including Any Pins). . . . . . . . . Core Buildup for Bridge/Ret. (incl. any pins). Diagnostic casts (each). . . . . . . . . . . . . . . . .
$20.00 $20.00 $25.00 $10.00
$45.00 $20.00 $10.00 $20.00 $10.00 $10.00 $85.00 $85.00 $10.00
Member Co-pay
Full cast predominantly base metal (per unit). . . $365.00 Crown - Porcelain Fused to Pred. Base Metal . . $365.00 Porcelain fused to pred. base metal (per unit) . . $365.00
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***
. . . $40.00 . . . $50.00 . . . $60.00 . . . $80.00
. . $105.00 . . $135.00 . . $135.00 . . $135.00
. . . $10.00 . . $225.00
3/4 cast predominantly base metal (per unit) Cast noble metal (per unit) . . . . . . . . . . . . . . Prefabricated stainless steel-resin crown. . . Cast predominantly base metal (per unit). . . Porcelain fused- pred. base metal (per unit) Porcelain fused to noble metal (per unit) . . . Crown- 3/4 cast pred. base metal (per unit). Resin-based composite crown, anterior . . . Provisional crown . . . . . . . . . . . . . . . . . . . . . Cast post and core. . . . . . . . . . . . . . . . . . . . Prefabricated post and core. . . . . . . . . . . . .
. . . $385.00 . . . $395.00 . . . . $70.00 . . . $385.00 . . . $365.00 . . . $385.00 . . . $385.00 . . . $185.00 . . . $120.00 . . . $105.00 . . . $105.00