Page 4 - Golden Dental Plans – HealthChoice Small Business Dental Program

HealthChoice of Michigan Small Business Covered Services and Co-Payment Schedule
Endodontics** (interior of tooth)
Repair of Prosthesis
Anterior Root Canal Therapy. . . . . . Premolar Root Canal Therapy. . . . . Molar Root Canal Therapy . . . . . . . Retreat of Previous RCT - anterior . Retreat of Previous RCT - premolar 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). . . . . . . . .
Member Co-pay
. . . . . . . . . . . $250.00 . . . . . . . . . . . $285.00 . . . . . . . . . . . $350.00 . . . . . . . . . . . $290.00 . . . . . . . . . . . $350.00 . . . . . . . . . . . $410.00 . . . . . . . . . . . . $40.00 . . . . . . . . . . . . $50.00 . . . . . . . . . . . $375.00 . . . . . . . . . . . $350.00 . . . . . . . . . . . $400.00 . . . . . . . . . . . $150.00 . . . . . . . . . . . . $15.00
Member Co-pay
Periodontics** (gums and supporting tissue)
Member Co-pay
Comprehensive Periodontal Evaluation. . . . . . . . . . $25.00 Scaling due to Inflammation . . . . . . . . . . . . . . . . . . $20.00 Full Mouth Debridement . . . . . . . . . . . . . . . . . . . . . $30.00 Periodontal Maintenance. . . . . . . . . . . . . . . . . . . . . $35.00 Perio Scaling/Root Planing (>=4). . . . . . . . . . . . . . . $65.00 Perio Scaling/Root Planing (<=3). . . . . . . . . . . . . . . $55.00 Site Specific Therapy (per tooth) . . . . . . . . . . . . . . . $50.00 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
CompleteUpperDenture ...................$425.00 Complete Lower Denture. . . . . . . . . . . . . . . . . . . . $425.00 ImmediateUpperDenture ..................$475.00 Immediate Lower Denture . . . . . . . . . . . . . . . . . . . $475.00 Partial U/L Denture- cast metal framework . . . . . . $495.00 with resin bases (inc. regular clasps, rests & teeth) PartialDenture(acrylicresinbase) ............$395.00 Tissue Conditioning (per arch). . . . . . . . . . . . . . . . . $55.00 Denture/Partial adjustment (existing). . . . . . . . . . . . $10.00 Interim Complete Denture (Maxillary/Mandibular . $165.00
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. . . . . . . . . . . . . . . . . $35.00 Repair Cast Framework. . . . . . . . . . . . . . . . . . . . . . . . . $80.00 Repair or replace broken clasp . . . . . . . . . . . . . . . . . . $105.00 Add tooth to existing partial denture. . . . . . . . . . . . . . . $50.00 Add clasp to existing partial denture. . . . . . . . . . . . . . $120.00 Reline Complete Maxillary Denture Chairside . . . . . . . $110.00 Reline Complete Mandibular Denture Chairside . . . . . $110.00 Reline Maxillary Partial Denture Chairside. . . . . . . . . . $110.00 Reline Mandibular Partial Denture Chairside. . . . . . . . $110.00 Reline Complete Maxillary Denture Laboratory. . . . . . $175.00 Reline Complete Mandibular Denture Laboratory . . . . . $175.00 Reline Mandibular Partial Denture Laboratory. . . . . . . $175.00
Oral Surgery**
Member Co-pay
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 Alveoloplasty in conj. w/exts. (1-3 teeth or spaces) . . . $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)
Orthodontics*** Lifetime Maximum
• $1,800.00 (up to age 19, comprehensive case only) • $1,200.00 (Adult Member, Spouse, and dependent
19 and older)