Page 4 - Golden Health Choice Small Business

HealthChoice of Michigan Small Business Covered Services and Co-Payment Schedule
Endodontics** (interior of tooth)
Member Co-pay
Anterior Root Canal Therapy . . . . . . . . . . . . . . . $185.00 Premolar Root Canal Therapy . . . . . . . . . . . . . . $250.00 Molar Root Canal Therapy . . . . . . . . . . . . . . . . . $350.00 Retreat of Previous RCT - anterior . . . . . . . . . . . $290.00 Retreat of Previous RCT - premolar. . . . . . . . . . $350.00 Retreat of Previous RCT - molar . . . . . . . . . . . . $410.00 Therapeutic Pulpotomy . . . . . . . . . . . . . . . . . . . . $55.00 Retrograde filling (per root). . . . . . . . . . . . . . . . . . $60.00 Apicoectomy - anterior. . . . . . . . . . . . . . . . . . . . $280.00 Apicoectomy - premolar (first root). . . . . . . . . . . $310.00 Apicoectomy - molar (first root) . . . . . . . . . . . . . $350.00 Apicoectomy (each addt'l. root) . . . . . . . . . . . . . $100.00 Pulp Cap (direct/indirect) . . . . . . . . . . . . . . . . . . . $10.00
Periodontics** (gums and supporting tissue)
Member Co-pay
Comprehensive Periodontal Evaluation . . . . . . . . $25.00
Repair of Prosthesis
Member Co-pay
Repair denture/partial (resin base) . . . . . . . . . . . . $50.00 Replace missing/broken tooth on denture/partial. $30.00
Scaling due to Inflammation. . . .
Full Mouth Debridement. . . . . . .
Periodontal Maintenance . . . . . .
Perio Scaling/Root Planing (>=4)
Perio Scaling/Root Planing (<=3)
Site Specific Therapy (per tooth) Gingivectomy/Gingivoplasty (>=4 or bounded) . $210.00 Gingivectomy/Gingivoplasty (<=3 or bounded) . $210.00 Gingival Flap Procedure (>=4 or bounded) . . . . $310.00 Gingival Flap Procedure (<=3 or bounded) . . . . $270.00 Osseous Surgery (>=4 or bounded) . . . . . . . . . . $290.00 Osseous Surgery (<=3 or bounded) . . . . . . . . . . $290.00
Prosthodontic (removables)
Member Co-pay
Complete Upper Denture . . . . . . . . . . . . . . . . . $425.00 Complete Lower Denture . . . . . . . . . . . . . . . . . . $425.00 Immediate Upper Denture . . . . . . . . . . . . . . . . . $475.00 Immediate Lower Denture . . . . . . . . . . . . . . . . . $475.00 Partial U/L Denture- cast metal framework . . . . $495.00 with resin bases (inc. regular clasps, rests & teeth) Partial Denture (acrylic resin base) . . . . . . . . . . . $395.00 Tissue Conditioning (per arch) . . . . . . . . . . . . . . . $55.00 Denture/Partial adjustment (existing) . . . . . . . . . . $10.00 Interim Complete Denture (Maxillary/Mandibular . . $165.00
Simple extraction of single primary tooth . . . . . . . $32.00 Simple extraction of single tooth . . . . . . . . . . . . . $32.00 Surgical removal of an erupted tooth . . . . . . . . . . $60.00 Removal impacted tooth- soft tissue . . . . . . . . . . $85.00 Removal impacted tooth- partially bony . . . . . . . $115.00 Removal impacted tooth- completely bony . . . . $170.00 Removal Impacted Tooth- completely bony (diff.) . $195.00 Surgical removal of residual tooth roots . . . . . . . $150.00 Surgical access of an unerupted tooth . . . . . . . . $180.00 Alveoloplasty in conj. w/exts. (4+ teeth or spaces) . $75.00 Alveoloplastyinconj.w/exts.(1-3teethorspaces) $60.00 Alveoloplasty not in conj. w/exts. (4+ teeth or spaces) . $95.00 Alveoloplasty not in conj. w/exts. (1-3 teeth or spaces). $95.00 Removal of exostosis (per site) . . . . . . . . . . . . . . $135.00 Incision & drainage of abscess (intraoral soft tiss.) . . $30.00 Intravenous moderate sedation first 15 minutes . . . . $95.00 Intravenous moderate sedation . . . . . . . . . . . . . . . . . $35.00 (each additional 15 minutes)
Unclassified Treatment
Member Co-pay
Office visit for observation (no other treatment) . . . . . $10.00 Treatment of complications (post-surg. minor-per visit) . $15.00
ANNUAL MAXIMUM for Primary Care Dentistry UNLIMITED Orthodontics*** Lifetime Maximum
• $1,800.00 (up to age 19, comprehensive case only) • $1,200.00 (Adult Member, Spouse and dependent
19 and older)
. . . . . . . . . . . . . $20.00 . . . . . . . . . . . . . $30.00 . . . . . . . . . . . . . $35.00 . . . . . . . . . . . . . $65.00 . . . . . . . . . . . . . $55.00 . . . . . . . . . . . . . $50.00
Repair Partial Cast Framework. . . . . . . . . Repair or replace broken clasp . . . . . . . . . Add tooth to existing partial denture. . . . . Add clasp to existing partial denture . . . . Reline complete or partial denture (office) Reline complete or partial denture (lab) . .
Oral Surgery**
. . . . . . $80.00 . . . . . . $75.00 . . . . . . $50.00 . . . . . . $75.00 . . . . . $100.00 . . . . . $125.00
Member Co-pay
8585 Small Business SP