Procedure |
Patient Pays |
|
Procedure |
Patient Pays |
Diagnostic |
|
Crowns/Bridges
All charges for crown and bridge are per unit. There will be an additional charge for the actual cost for gold/high noble metal for the procedures identified by an asterisk. |
Office Visit |
$10.00 |
|
Exam-Periodic** |
No Charge |
|
Exam-Comprehensive** |
No Charge |
|
X-ray, Intraoral, Complete Series (including bitewings)** |
No Charge |
|
Inlay or Onlay, Metallic* |
$220.00 |
X-ray, Intraoral, First Film |
No Charge |
|
Crown, Porcelain/Ceramic Substrate |
$260.00 |
X-ray, Intraoral, Additional |
No Charge |
|
Crown, Porcelain Fused to Metal* |
$260.00 |
X-ray, Intraoral, Occlusal |
No Charge |
|
Crown, Full Casts Metal* |
$260.00 |
X-ray, Extraoral, First Film |
No Charge |
|
Crown, ¾ Casts Metal * |
$250.00 |
X-ray, Extraoral, Additional |
No Charge |
|
Recement Inlays/Crowns |
$15.00 |
X-ray, Bitewing-Single Film ** |
No Charge |
|
Crown, Stainless Steel Primary Tooth (Child) |
$45.00 |
X-ray, Bitewing-Two Films |
No Charge |
|
Crown, Prefab. Stainless Steel Permanent Tooth |
$60.00 |
X-ray, Bitewing-Four Films |
No Charge |
|
Core Build, including pairs |
$45.00 |
X-ray, Panoramic |
No Charge |
|
Cast Post and Core, in add. to Crown |
$80.00 |
Pulp Vitality Test |
No Charge |
|
Prefab. Post and Core, in add. to Crown |
$71.00 |
Diagnostic Casts |
No Charge |
|
Pontic, Full Casts Metal |
$260.00 |
Preventive |
|
Pontic, Porcelain Fused to Metal |
$260.00 |
Prophylaxis-Adult (limit 2 per year) |
No Charge |
|
Crown, Abutment, Porcelain Fused to Metal |
$260.00 |
Prophylaxis-Child (limit 2 per year) |
No Charge |
|
Crown, Abutment, Full Casts Metal* |
$260.00 |
Topical Application of Fluoride (1 per year under age of 16) |
No Charge |
|
Recement Bridge |
$20.00 |
Oral Hygiene Instructions |
No Charge |
|
Add. Charge per Unit for Full Mouth Rehabilitation |
$125.00 |
Sealant-per Tooth (under age 16)** |
$10.00 |
|
Full Mouth rehabilitation is defined as 6 or more units of covered crowns and or pontics under one treatment plan. |
Space Maintainers-Fixed |
$65.00 |
|
Space Maintainers-Removable (includes adjustments within 6 months of installations) |
$80.00 |
|
Endodontics |
Recement Space Maintainers |
$15.00 |
|
Pulp Cap, Direct or Indirect |
No Charge |
Restorative |
|
Therapeutic Pulpotomy |
$35.00 |
PRIMARY TEETH |
|
Root Canal, Anterior |
$120.00 |
Amalagram-1-4 Surfaces or More |
No Charge |
|
Root Canal, Bicuspid |
$140.00 |
PERMANENT TEETH |
|
Root Canal, Molar |
$280.00 |
Amalagram-1-4 or More Surfaces |
No Charge |
|
Apicoectomy/Periradicular Surgery, Anterior |
$130.00 |
Resin-1-4 or More Surfaces or Incisal Angle, Anterior |
No Charge |
|
Apicoectomy/ Periradicular Surgery, Bicuspid- 1st root |
$130.00 |
Sedative Filling |
$8.00 |
|
Apicoectomy/ Periradicular Surgery, Molar – 1st Root |
$150.00 |
Pin Retention, exclusive of Restoration |
$6.00 |
|
Apicoectomy/ Periradicular Surgery Each Additional Root |
$90.00 |
** Frequency and/or age limitations may apply to these services. These limits are described in the booklet/certificate or evidence of coverage.
Endodontics-continued |
|
Interim Partial Upper/Lower Partial (Stayplate) |
$95.00 |
Retrograde Filling per Root |
$65.00 |
|
Tissue Conditioning, Upper or Lower |
$25.00 |
Sedative Filling |
$8.00 |
|
Oral Surgery |
Root Amputation per Root |
$80.00 |
|
Extraction, Single Tooth |
No Charge |
Periodontics |
|
Extraction, Each Additional Tooth |
No Charge |
Gingivectomy or Gingivoplasty per Quadrant (limit 1 per quad every 3 years) |
$120.00 |
|
Root Removal, Exposed Root |
$20.00 |
Gingivectomy or Gingivoplasty per Tooth (limit 1 per site every 3 years) |
$40.00 |
|
Surgical Extraction of an Erupted Tooth |
$36.00 |
Gingical Curettage, Surgical per
Quadrants (Limit of 4 separate quadrants
Every 2 years) |
$75.00
|
|
Removal of Impacted Tooth, Soft Tissue |
$60.00 |
Gingival Flap Procedure – per quad |
$140.00 |
|
Removal of Impacted Tooth, Partially Bony |
$72.00 |
Osseous Surgery per Quadrant (including flap entry and closure) (limit 1 per quad. every 3 years) |
$325.00 |
|
Removal of Impacted Tooth, Completely Bony |
$110.00 |
Periodontal Scaling & Root Planning per Quadrant (Limit of 4 separate quadrants every 2 years) |
$60.00 |
|
Surgical Removal of Root Tip, Root Recovery |
$35.00 |
Periodontal Maintenance Procedures (1 in 12 months-following active therapy) |
$40.00 |
|
Surgical Exposure of Unerupted, Impacted Tooth to Aid Eruption |
$70.00 |
Prosthodontics-Removable* |
|
Biopsy of Hard or Soft Tissue |
$80.00 |
Complete Upper or Lower Denture |
$320.00 |
|
Alveoplasty in Conjunction with Extractions (per Quadrant) |
$35.00 |
Immediate Upper or Lower Denture (does not include charge for reline) |
$330.00 |
|
Alveoplasty Not in Conjunction with Extractions (per Quadrant) |
$60.00 |
Upper and Lower Partial Denture Resin Base-Including Clasps, Rests and Teeth |
$300.00
|
|
Incision and Drainage, Intraoral Abscess |
$30.00 |
Upper of Lower Partial Cast Metal Base- Including Clasps, Rests and Teeth |
$400.00 |
|
Frenectomy |
$90.00 |
Prosthodontics-Removable |
|
Other (Adjunctive) Services |
Adjust Complete Denture Upper or Lower |
$10.00 |
|
Consultation Appointment |
No Charges |
Adjust Partial Denture Upper or Lower |
$10.00 |
|
Occlusal Guards-for bruxism only (limit 1 every 3 years) |
$70.00 |
Repairs To Prosthetics |
|
Occlusal Adjustment, Limited |
$10.00 |
Repair Broken Acrylic, Complete Denture Upper or Lower |
$30.00 |
|
Occlusal Adjustment, Complete |
$60.00 |
Replace One Tooth on Complete Denture |
$25.00 |
|
Emergency Services |
Repair Acrylic, cast Frame, Broken Clasp |
$35.00 |
|
Oral Evaluation, Problem Focused |
No Charges |
Replace Broken Tooth, Partial |
$35.00 |
|
Emergency Palliative Treatment |
$10.00 |
Add Tooth to Existing Partial |
$35.00 |
|
Orthodontics |
Add Clasp to Existing Partial |
$45.00 |
|
Orthodontic Screening Exam |
$30.00 |
Rebase Complete Upper/Lower Denture |
$86.00 |
|
Diagnostic Records |
$150.00 |
Rebase Patial Upper or Lower Denture |
$86.00 |
|
Comprehensive Orthodontic |
|
Reline Complete Upper/Lower Denture |
$50.00 |
|
Adolescent |
$1845.00 |
Reline Partial Upper/Lower Denture |
$50.00 |
|
Adult |
$1845.00 |
Reline Complete Upper/Lower Denture (Laboratory) |
$95.00 |
|
Orthodontic Retention |
$275.00 |
Reline Partial Upper/Lower Denture (Laboratory) |
$95.00 |
|
|
Aetna DMO Monthly Rates:
Employee Only: $15.98*
Employee and One: $35.19*
Employee and Family $57.09*
* Premiums are collected a month in advance
**Please note that you must pick a general dentist if electing the DMO plan. Failure to pick a general dentist will result in delays in treatment that may take over a month to resolve. You can locate a provider near you by going to Aetna’s website at www.Aetna.com and using the doc find option or by calling Aetna’s Member Service Department at 1-800-843-3661.
Emergency Dental Care*
DMO participating dentists will arrange for treatment for your dental emergencies at the DMO level of benefits. If the emergency occurs more than 50 miles from home, you have limited coverage for certain treatment by a non-participating dentist. The services must be needed to relieve pain or prevent the worsening of a condition that would be caused by delay of treatment. The benefit for certain treatment is the dentist's charge up to a $100 limit. Covered emergency services may vary, based on state law.
Please refer to dental insurance contract for policy provision and exclusions.
Please note that the Aetna DMO Dental Plan is only available in the following states:
|
Arizona |
Kansas |
New York |
Tennessee |
California |
Louisiana |
Ohio |
Texas |
Colorado |
Massachusetts |
Oklahoma |
Virginia |
Florida |
Michigan |
Oregon |
Washington |
Georgia |
Nevada |
Pennsylvania |
Wisconsin |
Idaho |
New Jersey |
South Dakota |
Utah |
|
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