Sample Discounted Fees and Savings

Procedure Name	Usual Fee*	Discounted Fee (for plan members)**	Member Savings
Routine 6 Month Checkup	$40	$24	$16
In-Depth Checkup	$67	$37	$30
Full Mouth X-Rays	$104	$65	$39
Bitewings - Four Films	$49	$25	$24
Panoramic Film	$87	$50	$37
Adult Teeth Cleaning	$75	$44	$31
Child Teeth Cleaning	$53	$32	$21
Protective Sealant - Per Tooth	$43	$26	$17
1 Surface White Filling for U or L Front Tooth	$121	$71	$50
Single Crown - Porcelain	$867	$566	$301
Single Crown - Porcelain or Noble Metal	$838	$549	$289
Root Canal Treatment - Molar	$829	$522	$307
Perio Scaling & Root Planning (Per Quandrant)	$208	$123	$85
Full Upper Denture	$1252	$725	$527

NOTE: For procedures not listed, contact an authorized provider for your cost.

The sample table above is a small selection of common procedures discounted by Aetna Dental Access. The procedures discounted under the Aetna Dental Access offer similar savings to the samples above.

This fee schedule is only to be used as a guide to determine approximate prices for dental services in the geographic area noted. The discounted fee schedule amount reflects average fee information currently available on our systems. Individual dentist fee schedules may differ. Aetna makes no guarantee as to the accuracy of any particular fee amount. In order to determine the specific rates for a dental provider, you should contact the dental provider directly.

* Source: DentalPlans.com (DP.C) 2005 Survey Sample Average National Discount Fees. Fees may vary slightly by region.

** Discounted fees are listed for visits to a particular general dentist. Members will be charged the provider's Aetna Dental Access contracted fees. Charges may vary from the sample fee schedule above.

This program is based geographically by ZIP code in terms of provider participation and location. Fee schedules and savings may very by ZIP code and by provider within a ZIP code.