Aetna Dental Access (only $6.95 a month)

This plan also include Vision and Prescription Drug Plan

Procedure Description	Usual Fee	Member  Pay	Member Savings
Routine 6 Month Check-Up	$40	$22	$18
Full Mouth X-Rays	$104	$53	$51
Four Bitewing X-Rays	$49	$25	$24
Panoramic Film	$87	$48	$39
Adult Teeth Cleaning	$75	$39	$36
Child Teeth Cleaning	$53	$31	$22
Protective Sealant / Tooth	$41	$22	$19
1 Surface White Filling for U or L Front Tooth	$110	$62	$48
Single Crown - Porcelain on High Noble Metal	$867	$515	$352
Single Crown - Porcelain on Noble Metal	$838	$495	$343
Root Canal Treatment - Molar	$794	$480	$314
Period Scaling and Root Planning	$208	$115	$93
Full Upper Denture	$1,252	$675	$577

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Fully Insured Dental From Aetna

call for Pricing (724)612-7458

	Aetna PPO Plus Plan pays*	Aetna PPO Plan pays*
Diagnostic and preventive	100%	80%
Periodontal maintenance cleanings	80%	50%
Denture repair, rebase and relining	80%	50%
Basic restorative (fillings)	50%	50%
Oral surgery	50%	50%
Endodontics (root canals)	50%	50%
Additional coverage
Periodontics	50%	50%
Crown and cast restorations	50%	50%
Prosthodontics (dentures)	50%	50%
Temporomandibular joint (TMJ) dysfunction	Not covered	Not covered
Deductibles and maximums per member enrolled
Deductible (calendar year)	$50	$100
Maximum benefit (calendar year)	$1,200	$1000
Waiting period
Basic	6 months	6 months
Major	18 months	18 months

Above list of covered services is representative.

*Out-of-network coverage is limited to a maximum of the plan’s payment, which is based on the negotiated, contract rate for in-network providers in a particular

Vision from ECI (Include with Aetna Dental Access)

PRODUCT / MEDICAL PROCEDURE SUGGESTED RETAIL YOUR COST YOUR SAVINGS % SAVINGS Eye Exam $ 50.00 Free * $ 50.00 100% Single-Vision, Polo Classic Frames with UV protection, tint and scratch resistant coating $ 257.00 $ 133.00 $ 124.00 48% Progressive, Guess Model 251 Frames with UV protection and scratch resistant coating $ 419.00 $ 225.00 $ 194.00 46% Disposable Contact Lenses (per box) $ 24.75 $ 18.95 $ 5.80 23% Revo Advanced Oval Sunglasses* $ 275.00 $ 149.00 $ 126.00 45% Serengeti Navigator (Model DR5403) Sunglasses * $ 150.00 $ 85.00 $ 65.00 43% LASIK Surgery * $ 2,500.00 $ 2,000.00 $ 500.00 20% Cataract Surgery * $ 2,500.00 $ 800.00 $ 1,700.00 68% CO2 Laser Skin Resurfacing** $ 5,000.00 $ 4,000.00 $ 1,000.00 20% *Not ALL providers offer FREE eye exams. Please check your zip code/area for a complete list.

 

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