Dental Insurance that Covers Simple Tooth Extractions

How Much Does It Cost to Have a Tooth Pulled?

At some point, it may be necessary to remove one tooth to preserve the health of the rest of your mouth. Getting a tooth pulled can be expensive without the help of good dental insurance. Momentum Insurance Plans Inc. in Wisconsin offers dental insurance plans covering simple extractions and greatly reducing your out-of-pocket costs. Individuals in the DHA network can save up to 75% of the cost of extractions. 

Basic Extraction Cost without Insurance: $225

Impacted Extraction Cost without Insurance: $275

Simple Extraction Coverage with Momentum Gold & Platinum Insurance Plans: 60-75% Coverage

Simple extractions are most often needed before orthodontic procedures due to overcrowding. Your dentist may also decide to extract a tooth if it is dead, or severely decayed. If a tooth is dead and the nerves have retracted this process is nearly painless. As a general rule, removal of teeth above the gum line requires a simple extraction, while teeth below the gum line require surgical extraction.

*Pricing based upon a 3-4 Person Family. For more than 4 family members, add $25.00 for each additional member.

Rates are subject to change. Confirm current rates with our Sales Department by calling 608.729.6500.

Individual Dental Insurance Coverage

Don’t get caught off guard with a sudden extraction expense. Simple extractions are considered basic restorative services. Gold & Platinum individual dental plans offer 60% and 75% coverage on simple extractions following a 6 month waiting period. Depending on your previous policy you may be eligible to skip this waiting period.

Group Plan Simple Extraction Coverage

If your employees work hard, give them the gift of dental health with our group dental plans. Group plans allow employees & employers to choose what percentage of various services they want covered, including simple extractions. Group dental plans allow employees and employers to choose what percentage of various services they want covered, including simple extractions.

Contact the Wisconsin dental insurance providers at Momentum Plans to discuss your options for a dental plan covering tooth extractions.

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Plan and Coverage Options

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SELECT YOUR PLAN (must choose an option)

Protect Plan:

Dental Health Associates Network

Gold Plan:

Dental Health Associates Network Commercial Network

Platinum Plan:

Dental Health Associates Network Commercial Network

Coverage Type

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Select the number of Dependents One Two Three Four Five

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Price Per Month:

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Member Information

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First Name*

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Last Name*

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Home Address*

City*

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Primary Phone*

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Marital Status Married Single

*Date of Birth

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How have you heard about us?

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Dependent Information

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No dependent info is needed if you choose single in plan coverage.

1. Dependent Info

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2. Dependent Info

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Female

Date of Birth / /

Dependent Relationship (spouse, son, daughter) Spouse Son Daughter Other

3. Dependent Info

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Female

Date of Birth / /

Dependent Relationship (spouse, son, daughter) Spouse Son Daughter Other

4. Dependent Info

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Female

Date of Birth / /

Dependent Relationship (spouse, son, daughter) Spouse Son Daughter Other

5. Dependent Info

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Female

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Coordination of Benefits & Prior Coverage

Step 4 of 5

Just a Couple More Questions:

Are you, your spouse, or other dependents(s) covered by any other dental plan that will remain in effect

Yes No

Which Family members will be covered? Self Spouse Dependent(s)

Select the number of Dependents

One Two Three Four Five

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Has applicant had previous dental coverage?

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Which Family members had previous insurance? Self Spouse Dependent(s)

Select the number of Dependents One Two Three Four Five

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /

Coverage Ended On / /

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

Name of Person Insured

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Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

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Complete Your Purchase of a Momentum Insurance Plan

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MONTHLY COST:

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Total Due Today:

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Acceptance

I accept the Individual Plan coverage provided by Momentum Insurance Plans, Inc. I understand that by accepting insurance coverage, I am required to remit premiums according to the method of payment selected below on or before the 20th day of the month preceding the month of coverage for which payment is being made. Addition or deletion of dependents, and any other changes to coverage are allowed only based on a qualifying event as described in the Individual Plan policy. Coverage will be effective only upon acceptance and approval by Momentum Insurance Plans, Inc.

By signing this form, I certify that all information supplied is true to the best of my knowledge. I understand that all benefits for myself and my eligible dependents will be provided in accordance with the terms of the plan(s) in which I have enrolled and I agree to abide by the terms and conditions provided in the plan(s).

Please Sign The Electronic Signature Form Below

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By my signature above, I authorize Momentum Insurance Plans, Inc. to initiate a debit entry to the credit card account (Discover, MasterCard, Visa) indicated above in the amount of 3 months premium for the initial payment. Each month thereafter, debits will be made on the 20th day of the month, prior to the coverage month, for each monthly payment. This authority is to remain in full force and effective until Momentum Insurance Plans, Inc. and said financial institution have received written notification from me of its termination in such time and manner as to afford Momentum Insurance Plans, Inc. and said financial institution reasonable opportunity to act upon it. This card will be used for reoccurring payments unless we hear from you. Please contact us at 608.729.6500 to make other arrangements for reoccurring payments.

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