¤ Aetna US Healthcare Vision One Program | PEO Employee Benefit Plans & Group Healthcare Benefits | Outsourcing Small Business Human Resources | Health Care Coverage, Workmans Compensation & Employer HR Specialist

Aetna US Healthcare Vision One Program

(Included in both PPO and DMO Dental programs at no additional cost)

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.

Vision One Benefits*		Solid or gradient tint	$8.00
Eyeglass Frames (retail prices)		Glass	$18.00
Up to $60.00	$16.00	Photochromic	$34.00
$61.00 to $80.00	$26.00	Antireflective	$35.00
$81.00 to $100.00	$36.00	Eyeglass Fitting Fee
$101.00 to $200.00	50% off retail	Includes unlimited adjustments	$10.00
Lenses per Pair (uncoated plastic)		Eye Exams for Plans that Do Not Cover Eye Exams
Single Vision	$28.00	Eye Exams for Plans that Do Not Cover Eye Exams
Bifocal	$48.00	For Eyeglasses	$34.00
Trifocal	$58.00	For Contact Lenses	$10.00 off retail fee
Lenticular	$98.00	Eye Exams for Plans that Do Cover Eye Exams
Lens Options per Pair (add to lens prices above)		Eye Exams for Plans that Do Cover Eye Exams
Standard Progressive(no-line bifocals)	$50.00	Refer to your health benefits plan documents
Polycarbonate	$30.00	Contact Lenses
Scratch-resistant coating	$12.00	Visit any Vision One location and receive up to a 20% discount (10% on disposables) off retail prices
Ultraviolet coating	$12.00

Call 1-800-391-LENS to order replacement contact lenses for additional savings and convenience. For Items not listed above, visit any Vision One location and receive a 20% discount off retail prices. Visit one of Cole Vision’s National Lasik Network providers and receive a 15% discount off the provider’s retail fee, or 5% off the promotional price for the laser vision correction procedure.

The Vision One Program is available as part of either the Aetna DMO or the PPO Dental Plans requires that you use a participating provider to be covered for services or receive reimbursement.

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National CMServices is a professional employer organization (peo) and staff leasing company. Our human resource administration services and outsourcing solutions provide pay-as-you-go workers compensation insurance, direct deposit payroll processing provider to small business, large organizations and over 30,000 work site employees. Employee benefits include group health care coverage plans, a dental program and hr resources. Providing management solution rate quotes, workmans comp benefit rates and employment agency service quote. Powered by Altec Design | Optimization by WebRanking.com