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Employee Benefits
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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

 

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)

 

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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