| Aetna Dental AccessSM |
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| SAMPLE FEE SCHEDULE* |
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| Fee schedules are established by geographic area. This is a sample. Aetna makes no guarantee as to the accuracy of any particular fee amount shown in this schedule. Once you have registered in the plan, you will be able to access the fees for common dental procedures in your area online using Aetna NavigatorSM. |
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| * Geographic Area; All Virginia zip codes except Northern Virginia |
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| Dental Procedure Codes and Nomenclature© 2005 American Dental Association |
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| ADA CODE | Description | Aetna Fee | Out-of-Network |
| D0120 | Periodic Oral Evaluation | $22 | $32 |
| D0140 | Limited Oral Evaluation - Problem Focused | $27 | $47 |
| D0150 | Comprehensive Oral Evaluation | $31 | $48 |
| D0210 | X-ray Intraoral - Complete Series Including Bitewings | $56 | $94 |
| D0220 | X-ray Intraoral Periapical, First Film | $10 | $19 |
| D0230 | X-ray Intraoral Periapical, Each Additional Film | $6 | $15 |
| D0270 | X-ray Bitewing, Single Film | $11 | $17 |
| D0272 | Bitewings, Two Films | $18 | $29 |
| D0274 | Bitewings, Four Films | $24 | $43 |
| D0330 | X-ray Panoramic Film | $44 | $78 |
| D1110 | Prophylaxis - Adult | $43 | $58 |
| D1120 | Prophylaxis - Child | $30 | $43 |
| D1203 | Topical Application of Fluoride (prophylaxis not included) - Child | $16 | $26 |
| D1204 | Topical Application of Fluoride (prophylaxis not included) - Adult | $17 | $25 |
| D1351 | Sealant - Per Tooth | $24 | $36 |
| D2140 | Amalgam - One Surface, Primary or Permanent | $55 | $81 |
| D2150 | Amalgam - Two Surfaces, Primary or Permanent | $68 | $99 |
| D2160 | Amalgam - Three Surfaces, Primary or Permanent | $83 | $117 |
| D2330 | Resin-based Composite - One Surface, Anterior | $67 | $81 |
| D2331 | Resin-based Composite - Two Surfaces, Anterio | $89 | $102 |
| D2750 | Crown-Porcelain Fused to High Noble Metal | $541 | $728 |
| D2751 | Crown-Porcelain Fused to Predominantly Base Metal | $502 | $637 |
| D2752 | Crown-Porcelain Fused to Noble Metal | $524 | $616 |
| D3330 | Root Canal - Molar (Excluding Final Restoration) | $527 | $701 |
| D4260 | Osseous Surgery - Four or More Contiguous Teeth or Bounded Teeth
Spaces per Quadrant | $551 | $614 |
| D4341 | Periodontal Scaling and Root Planing - Four or More Contiguous Teeth or Bounded Teeth Spaces per Quadrant | $118 | $156 |
| D4910 | Periodontal Maintenance | $54 | $78 |
| D5110 | Complete Denture - Maxillary | $671 | $935 |
| D5120 | Complete Denture - Mandibular | $671 | $896 |
| D7210 | Surgical Removal of Erupted Tooth | $107 | $156 |
| D7240 | Removal of Impacted Tooth - Completely Bony | $208 | $315 |
| D8080 | Comprehensive Orthodontic Treatment of the Adolescent Dentition | $3,056 | $4,380 |
| D8090 | Comprehensive Orthodontic Treatment of the Adult Dentition | $3,211 | $4,599 |
| D9110 | Palliative Treatment of Dental Pain | $43 | $53 |
