If you wish to select or change your General Dentist or need assistance with selecting a Specialty Dentist, please contact Aetna Dental Customer Service at 1-800-275-1794 for assistance.


Diagnostic Dentistry

	ADA Codes Procedure Copayment
	D0120 Periodic oral exam/evaluation (2 per plan year*) No Charge D0140 Oral evaluation - problem focused $20 D0150 Clinical oral exam/evaluation (initial) No Charge D0160 Detailed and extensive oral evaluation - problem focused, by report No Charge D0170 Re-evaluation - limited, problem focused No Charge D0180 Comprehensive periodontal evaluation - new or established patient No Charge D0210 X-ray intraoral - complete series (including bitewings) No Charge D0220 X-ray intraoral - periapical - first film No Charge D0230 X-ray intraoral - periapical - each additional film No Charge D0240 X-ray intraoral - occlusal film No Charge D0250 X-ray extraoral - first film No Charge D0260 X-ray extraoral - each additional film No Charge D0270 X-ray bitewing - single film No Charge D0272 X-ray bitewings - two films No Charge D0274 X-ray bitewings - four films No Charge D0277 X-ray vertical bitewings - 7 to 8 films No Charge D0330 X-ray panoramic No Charge D0350 Oral/facial images No Charge D0415 Bacterial studies for determination of pathologic agents No Charge D0425 Caries susceptibility tests No Charge D0460 Pulp vitality tests No Charge D0470 Diagnostic casts (excluding ortho) No Charge D0472-80 Oral pathology procedures No Charge D0502 Other oral pathology procedures (by report) No Charge D9999 Unspecified diagnostic procedures (by report) No Charge D4999 Periodontal probing $12 D9430 Office Visit No Charge D9440 Office visit after regularly scheduled hours $30 D9999 Sterilization fee $5 *Plan year is a year starting September 1 and extending through August 31.

	ADA Codes Procedure Copayment
	D1110 Dental cleaning / prophylaxis - adult (2 per plan year*) $10 D1120 Dental cleaning / prophylaxis - child (12 years and under) (2 per plan year*) $10 D1201-05 Topical application of fluoride No Charge D1310 Nutritional counseling for the control of dental disease No Charge D1330 Oral hygiene instructions No Charge D1351 Sealant -- per tooth $10 D1510 Space maintainer - fixed - unilateral $90 D1515 Space maintainer - fixed - bilateral $90 D1520 Space maintainer - removable - unilateral $90 D1525 Space maintainer - removable - bilateral $90 D1550 Recementation of space maintainer $10 *Plan year is a year starting September 1 and extending through August 31.

	ADA Codes Procedure Copayment
	D2140 Amalgam - 1 surface, primary or permanent $20 D2150 Amalgam - 2 surfaces, primary or permanent $25 D2160 Amalgam - 3 surfaces, primary or permanent $30 D2161 Amalgam - 4 or more surfaces, primary or permanent $35 D2330 Resin-based composite - 1 surface, anterior $25 D2331 Resin-based composite - 2 surfaces, anterior $30 D2332 Resin-based composite - 3 surfaces, anterior $35 D2335 Resin-based composite - 4 or more surfaces or involving incisal angle, anterior $50 D2390 Resin-based composite crown - anterior $40 D2391 Resin-based composite - 1 surface posterior $45 D2392 Resin-based composite - 2 surfaces posterior $55 D2393 Resin-based composite - 3 surfaces posterior $65 D2394 Resin-based composite - 4 or more surfaces, posterior $71 D2410 Gold foil restoration - 1 surface $60 D2420 Gold foil restoration - 2 surfaces $140 D2430 Gold foil restoration - 3 surfaces $180

	ADA Codes Procedure Copayment
	D2510 Inlay - metallic - 1 surface $140 D2520 Inlay - metallic - 2 surfaces $170 D2530 Inlay - metallic - 3 or more surfaces $200 D2542 Onlay - metallic - 2 surfaces $250 D2543 Onlay - metallic - 3 surfaces $260 D2544 Onlay - metallic - 4 or more surfaces $270 D2610 Inlay - porcelain/ceramic - 1 surface $247 D2620 Inlay - porcelain/ceramic - 2 surfaces $297 D2630 Inlay - porcelain/ceramic - 3 or more surfaces $297 D2642 Onlay - porcelain/ceramic - 2 surfaces $317 D2643 Onlay - porcelain/ceramic - 3 surfaces $317 D2644 Onlay - porcelain/ceramic - 4 or more surfaces $327 D2650 Inlay - resin-based composite - 1 surface $172 D2651 Inlay - resin-based composite - 2 surfaces $182 D2652 Inlay - resin-based composite - 3 or more surfaces $212 D2662 Onlay-resin-based composite - 2 surfaces $212 D2663 Onlay-resin-based composite - 3 surfaces $222 D2664 Onlay-resin-based composite - 4 or more surfaces $237 D2710 Crown resin based composite (indirect) $318 D2712 Crown - ¾ resin-based composite (indirect) $318 D2720 Crown resin with high noble metal $368 D2721 Crown resin with predominantly base metal $260 D2722 Crown resin with noble metal $299 D2740 Crown - porcelain/ceramic substrate $399 D2750 Crown - porcelain fused to high noble metal $399 D2751 Crown - porcelain fused to predominantly base metal $350 D2752 Crown - porcelain fused to noble metal $389 D2780 Crown - ¾ cast high noble metal $399 D2781 Crown - ¾ cast predominately base metal $350 D2782 Crown - ¾ cast noble metal $389 D2783 Crown - ¾ cast porcelain/ceramic $350 D2790 Crown - full cast high noble metal $399 D2791 Crown - full cast predominantly base metal $350 D2792 Crown - full cast noble metal $389 D2794 Crown - titanium $399 D2910 Recement inlay, onlay or partial coverage restoration (by original dentist) No Charge D2910 Recement inlay, onlay or partial coverage restoration (by new dentist) $5 D2915 Recement cast or prefabricated post and core $5 D2920 Recement crown (by original dentist) No Charge D2920 Recement crown (by new dentist) $5 D2930 Prefabricated stainless steel crown - primary tooth $50 D2931 Prefabricated stainless steel crown - permanent tooth $55 D2932 Prefabricated resin crown No Charge D2933 Prefabricated stainless steel crown with resin window $65 D2934 Prefabricated esthetic coated stainless steel crown - primary tooth $65 D2940 Sedative filling $5 D2950 Core buildup, including any pins $55 D2951 Pin retention - per tooth, in addition to restoration No Charge D2952 Cast post and core, in addition to crown $62 D2953 Each additional cast post - same tooth $18 D2954 Prefabricated post and core, in addition to crown $58 D2957 Each additional prefabricated post - same tooth $15 D2961 Labial veneer (resin laminate) - laboratory $297 D2962 Labial veneer (porcelain laminate) - laboratory $380 D2971 Additional procedures to construct new crown under existing partial denture framework $15 D2975 Coping $148 D2980 Crown repair (by report) $30 D2999 Unspecified restorative procedure (by report) No Charge D2999 Temporary metal crown (with permanent) No Charge

	ADA Codes Procedure Copayment
	D3999 Endodontic consultation No Charge D3110 Pulp cap direct (excluding final restoration) No Charge D3120 Pulp cap indirect (excluding final restoration) No Charge D3220 Therapeutic pulpotomy (excluding final restoration) $35 D3310 Root Canal - Anterior $160 D3320 Root Canal - Bicuspid $180 D3330 Root Canal - Molar $240 D3351-53 Apexification / Recalcification No Charge D3410-21 Apicoectomy/Periradicular surgery - anterior, bicuspid $140 D3425 Apicoectomy/Periradicular surgery molar - first root $170 D3426 Apicoectomy/Periradicular surgery - each add'l root $90 D3430 Retrograde filling - per root $35 D3450 Root amputation - per root $55 D3470 Intentional replantation (including necessary splinting) $55 D3910 Surgical procedure for isolation of tooth with rubber dam $3 D3920 Hemisection (including any root removal), not including root therapy $66 D3999 Unspecified endodontic procedure (by report) No Charge D3999 Culturing canal No Charge

	ADA Codes Procedure Copayment
	D4999 Periodontal consultation, evaluation and treatment plan No Charge D4210 Gingivectomy or gingivoplasty - 4 or more contiguous teeth or bounded teeth spaces per quadrant $156 D4211 Gingivectomy or gingivoplasty - 1 to 3 contiguous teeth or bounded teeth spaces, per quadrant $94 D4240 Gingival flap procedure, including root planing - 4 or more contiguous teeth or bounded teeth spaces per quadrant $220 D4241 Gingival flap procedure, including root planing - 1 to 3 contiguous teeth or bounded teeth spaces, per quadrant $132 D4260 Osseous surgery (incl. flap entry and closure) - 4 or more contiguous teeth or bounded teeth spaces per quadrant $220 D4261 Osseous surgery (incl. flap entry and closure) - 1 to 3 contiguous teeth or bounded teeth spaces per quadrant $132 D4263 Bone replacement graft - first site in quadrant $150 D4264 Bone replacement graft - each add'l site in quadrant $150 D4265 Biologic materials to aid in soft and osseous tissue regeneration $150 D4320 Provisional splinting - intracoronal $60 D4321 Provisional splinting - extracoronal $60 D4341 Periodontal scaling and root planing - 4 or more teeth per quadrant $48 D4342 Periodontal scaling and root planing - 1 to 3 teeth per quadrant $29 D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis $40 D4910 Periodontal maintenance procedures (following active therapy) $35 D4920 Unscheduled dressing change (other than treating dentist) No Charge D4999 Unspecified periodontal procedure (by report) No Charge D4999 Home care instructions for periodontal management No Charge D4999 Post-therapeutic evaluation No Charge D4999 Non-surgical service periodontal No Charge

	ADA Codes Procedure Copayment
	D5110 Complete denture, maxillary $480 D5120 Complete denture, mandibular $480 D5110-20 Complete denture, maxillary or mandibular (duplicate) $250 D5130 Immediate denture - maxillary $508 D5140 Immediate denture - mandibular $508 D5211 Maxillary partial denture - resin base, including any conventional clasps, rests & teeth $493 D5212 Mandibular partial denture - resin base, including any conventional clasps, rests & teeth $493 D5213 Maxillary partial denture - cast metal framework with resin denture bases, including any conventional clasps, rests & teeth $568 D5214 Mandibular partial denture - cast metal framework with resin denture bases, including any conventional clasps, rests & teeth $568 D5225 Maxillary partial denture - flexible base (including any clasps, rests and teeth) $528 D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth) $528 D5410 Adjustment complete denture - maxillary (by original dentist) No Charge D5410 Adjustments complete denture - maxillary (by new dentist) $10 D5411 Adjustments complete denture - mandibular (by original dentist) No Charge D5411 Adjustments complete denture - mandibular (by new dentist) $10 D5421 Adjustments partial denture - maxillary (by original dentist) No Charge D5421 Adjustments partial denture - maxillary (by new dentist) $10 D5422 Adjustments partial denture - mandibular (by original dentist) No Charge D5422 Adjustments partial denture - mandibular (by new dentist) $10 D5510 Repair broken complete denture base $35 D5520 Repair missing or broken teeth - complete denture (per tooth) $20 D5610 Repair resin denture base $78 D5620 Repair cast framework $78 D5630 Repair or replace broken clasp $78 D5640 Replace broken teeth (per tooth) $78 D5650 Add tooth to existing partial denture $78 D5660 Add clasp to existing partial denture $78 D5670 Replace all teeth and acrylic on cast metal framework (maxillary) $164 D5671 Replace all teeth and acrylic on cast metal framework (mandibular) $164 D5710 Rebase complete maxillary denture $164 D5711 Rebase complete mandibular denture $164 D5720 Rebase maxillary partial denture $164 D5721 Rebase mandibular partial denture $164 D5730 Reline complete maxillary denture (chairside) $60 D5731 Reline complete mandibular denture (chairside) $60 D5740 Reline maxillary partial denture (chairside) $60 D5741 Reline mandibular partial denture (chairside) $60 D5750 Reline complete maxillary denture (laboratory) $75 D5751 Reline complete mandibular denture (laboratory) $75 D5760 Reline maxillary partial denture (laboratory) $75 D5761 Reline mandibular partial denture (laboratory) $75 D5810 Interim complete denture (maxillary) $60 D5811 Interim complete denture (mandibular ) $60 D5820 Interim partial denture (maxillary ) $90 D5821 Interim partial denture (mandibular ) $90 D5850 Tissue conditioning, maxillary $20 D5851 Tissue conditioning, mandibular $20 D5862 Precision attachment (by report) $150 D5899 Unspecified removable prosthodontic procedure, by report No Charge

	ADA Codes Procedure Copayment
	D6010 Surgical placement of implant body: endosteal implant $900

	ADA Codes Procedure Copayment
	D6053 Implant/abutment supported removable denture for completely edentulous arch $590 D6054 Implant/abutment supported removable denture for partially edentulous arch $687 D6058 Abutment supported porcelain/ceramic crown $461 D6059 Abutment supported porcelain fused to metal crown (high noble metal) $461 D6060 Abutment supported porcelain fused to metal crown (predominantly base metal) $412 D6061 Abutment supported porcelain fused to metal crown (noble metal) $451 D6062 Abutment supported cast metal crown (high noble metal) $461 D6063 Abutment supported cast metal crown (predominantly base metal) $412 D6064 Abutment supported cast metal crown (noble metal) $451 D6065 Implant supported porcelain/ceramic crown $461 D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, or high noble metal) $461 D6067 Implant supported metal crown (titanium, titanium alloy, or high noble metal) $461 D6068 Abutment supported retainer for porcelain/ceramic fixed partial denture $461 D6069 Abutment supported retainer for porcelain fused to metal fixed partial denture (high noble metal) $461 D6070 Abutment supported retainer for porcelain fused to metal fixed partial denture (predominantly base metal) $412 D6071 Abutment supported retainer for porcelain fused to metal fixed partial denture (noble metal) $451 D6072 Abutment supported retainer for cast metal fixed partial denture (high noble metal) $461 D6073 Abutment supported retainer for cast metal fixed partial denture (predominantly base metal) $412 D6074 Abutment supported retainer for cast metal fixed partial denture (noble metal) $451 D6075 Implant supported retainer for ceramic fixed partial denture $461 D6076 Implant supported retainer for porcelain fused to metal fixed partial denture (titanium, titanium alloy, or high noble metal) $461 D6077 Implant supported retainer for cast metal fixed partial denture (titanium, titanium alloy, or high noble metal) $461 D6094 Abutment supported crown - titanium $461 D6194 Abutment supported retainer crown for FPD - titanium $461

	ADA Codes Procedure Copayment
	The following bridge prices are listed on a per unit basis. A unit equals each tooth restored or replaced. D6205 Pontic - indirect resin based composite $350 D6210 Pontic - cast high noble metal $399 D6211 Pontic - cast predominantly base metal $350 D6212 Pontic - cast noble metal $389 D6214 Pontic - titanium $399 D6240 Pontic - porcelain fused to high noble metal $399 D6241 Pontic - porcelain fused to predominantly base metal $350 D6242 Pontic - porcelain fused to noble metal $389 D6245 Pontic - porcelain/ceramic $350 D6250 Pontic - resin with high noble metal $399 D6251 Pontic - resin with predominantly base metal $350 D6252 Pontic - resin with noble metal $389 D6253 Provisional pontic (interim of at least 6 months) $200 D6545 Retainer - cast metal for resin bonded ("Maryland") fixed prosthesis $236 D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis $236 D6600 Inlay - porcelain / ceramic, two surfaces $297 D6601 Inlay - porcelain / ceramic, three or more surfaces $297 D6602 Inlay - cast high noble metal, two surfaces $200 D6603 Inlay - cast high noble metal, three and more surfaces $230 D6604 Inlay - cast high noble metal, three and more surfaces $170 D6605 Inlay - cast predominantly base metal, three or more surfaces $200 D6606 Inlay - cast noble metal, two surfaces $190 D6607 Inlay - cast noble metal, three or more surfaces $220 D6608 Onlay - porcelain / ceramic, two surfaces $317 D6609 Onlay - porcelain / ceramic, three or more surfaces $317 D6610 Onlay - cast high noble metal, two surfaces $280 D6611 Onlay - cast high noble metal, three or more surfaces $290 D6612 Onlay - cast predominantly base metal, two surfaces $250 D6613 Onlay - cast predominantly base metal, three or more surfaces $260 D6614 Onlay - cast noble metal, two surfaces $270 D6615 Onlay - cast noble metal, three or more surfaces $280 D6624 Inlay - Titanium $200 D6634 Onlay - Titanium $280 D6710 Crown - indirect resin based composite $260 D6720 Crown - resin with high noble metal $368 D6721 Crown - resin with predominantly base metal $260 D6722 Crown - resin with noble metal $299 D6740 Crown - porcelain/ceramic $350 D6750 Crown - porcelain fused to high noble metal $399 D6751 Crown - porcelain fused to predominantly base metal $350 D6752 Crown - porcelain fused to noble metal $389 D6780 Crown - ¾ cast high noble metal $399 D6781 Crown - ¾ cast predominately base metal $350 D6782 Crown - ¾ cast noble metal $389 D6783 Crown - ¾ porcelain/ceramic $350 D6790 Crown - full cast high noble metal $399 D6791 Crown - full cast predominantly base metal $350 D6792 Crown - full cast noble metal $389 D6793 Provisional retainer crown (interim of at least 6 months) $200 D6794 Crown - titanium $399 D6930 Recement fixed partial denture (by original dentist) No Charge D6930 Recement fixed partial denture(by new dentist) $15 D6940 Stress breaker $148 D6950 Precision attachment $145 D6970 Cast post and core in addition to fixed partial denture retainer $62 D6971 Cast post as part of fixed partial denture retainer $62 D6972 Prefabricated post and core in addition to fixed partial denture retainer $58 D6973 Core build up for retainer, including any pins $55 D6975 Coping - metal $148 D6976 Each additional cast post - same tooth $18 D6977 Each additional prefabricated post - same tooth $15 D6980 Fixed partial denture repair (by report) $123

	ADA Codes Procedure Copayment
	D7111 Extraction, coronal remnants - deciduous tooth $12 D7140 Extraction, erupted tooth or exposed tooth (elevation and/or forceps removal) $24 D7210 Surgical removal of erupted tooth $38 D7220 Removal of impacted tooth, soft tissue $60 D7230 Removal of impacted tooth, partially bony $74 D7240 Removal of impacted tooth, completely bony $110 D7241 Removal of impacted tooth - completely bony with unusual surgical complications $121 D7250 Surgical removal of residual tooth roots (cutting procedure) $45 D7280 Surgical access of an unerupted tooth to aid eruption $90 D7282 Mobilization of erupted or malpositioned tooth to aid eruption $75 D7283 Placement of device to facilitate eruption of impacted tooth $18 D7285 Biopsy of oral tissue - hard (bone, tooth) $150 D7286 Biopsy of oral tissue - soft (all others) $150 D7287 Exfoliative cytology sample collection $40 D7288 Brush biopsy - transepithelial sample collection $40 D7310 Alveoloplasty in conjunctions with extractions - per quadrant $50 D7311 Alveoplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant $25 D7320 Alveoloplasty not in conjunction with extractions - per quadrant $75 D7321 Alveoplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant $38 D7471 Removal of lateral exostosis (maxilla or mandible) $150 D7472 Removal of torus palatinus $150 D7473 Removal of torus mandibularis $150 D7485 Surgical reduction of osseous tuberosity $150 D7510 Incision and drainage per abscess - intraoral soft tissue $35 D7511 Incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces) $38 D7520 Incision and drainage per abscess - extraoral soft tissue $40 D7521 Incision and drainage of abscess - extraoral soft tissue - complicated (includes drainage of multiple fascial spaces) $44 D7950 Osseous, osteoperiosteal, periosteal, or cartilage graft of the mandible or facial bones - autogenous or nonautogenous by report $150 D7953 Bone replacement graft for ridge preservation - per site $18 D7960 Frenulectomy (frenectomy or frenotomy) separate procedure $84 D7963 Frenuloplasty $86 D7970 Excision of hyperplastic tissue (per arch) $100 D7972 Surgical reduction of fibrous tuberosity $50

	ADA Codes Procedure Copayment
	D8999 Orthodontic exam (including consultation) $96 D8010 Limited orthodontic treatment of the primary dentition $385 D8020 Limited orthodontic treatment of the transitional dentition $385 D8070 Comprehensive orthodontic treatment of transitional dentition $1,580 D8080 Comprehensive treatment of adolescent dentition $1,880 D8090 Comprehensive treatment of adult dentition $1,880 D8220 Fixed appliance therapy (habit appliance) $175 D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) $66 D8999 Adjusting retainers No Charge D8999 Elastics No Charge D8999 Final orthodontic records No Charge D8999 Reattach brackets and bands (limit 3) No Charge D8999 Replace broken ligature wires (limit 3) No Charge

	ADA Codes Procedure Copayment
	D9110 Palliative (emergency) treatment of dental pain - minor procedure $15 D9211 Regional block anesthesia No Charge D9212 Trigeminal division block anesthesia No Charge D9215 Local anesthesia No Charge D9230 Analgesia, anxiolysis, inhalation of nitrous oxide $10 D9310 Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) No Charge D9450 Case presentation, detailed and extensive treatment planning No Charge D9940 Occlusal guard, by report $150 D9942 Repair and/or relining of occlusal guard $39 D9951 Occlusal adjustment - limited $10 D9952 Occlusal adjustment - complete $40 D9999 Preparatory fee No Charge

Any services not specifically listed are the responsibility of the member and are payable at the participating dentist's usual and prevailing charge.  If in doubt, ask your dentist.