Procedure | ADA Code | Usual Fee1 | With Plan2 | You Save | % Saved |
---|---|---|---|---|---|
Routine 6 month check-up | ADA Code: D0120 | Usual Fee1: $51.00 | With Plan2: $24 | You Save: $27 | Saving Percentage: 53% |
In depth check-up | ADA Code: D0150 | Usual Fee1: $86.00 | With Plan2: $33 | You Save: $53 | Saving Percentage: 62% |
Full mouth x-rays | ADA Code: D0210 | Usual Fee1: $143.00 | With Plan2: $70 | You Save: $73 | Saving Percentage: 51% |
Four bitewing x-rays | ADA Code: D0274 | Usual Fee1: $66.00 | With Plan2: $31 | You Save: $35 | Saving Percentage: 53% |
Panoramic film | ADA Code: D0330 | Usual Fee1: $115.00 | With Plan2: $47 | You Save: $68 | Saving Percentage: 59% |
Adult teeth cleaning | ADA Code: D1110 | Usual Fee1: $90.00 | With Plan2: $41 | You Save: $49 | Saving Percentage: 54% |
Child teeth cleaning | ADA Code: D1120 | Usual Fee1: $66.00 | With Plan2: $30 | You Save: $36 | Saving Percentage: 55% |
Protective sealant / tooth | ADA Code: D1351 | Usual Fee1: $56.00 | With Plan2: $32 | You Save: $24 | Saving Percentage: 43% |
1 surface silver filling for primary or permanent tooth | ADA Code: D2140 | Usual Fee1: $149.00 | With Plan2: $55 | You Save: $94 | Saving Percentage: 63% |
1 surface white filling for u or l front tooth | ADA Code: D2330 | Usual Fee1: $160.00 | With Plan2: $61 | You Save: $99 | Saving Percentage: 62% |
Single crown - porcelain on high noble metal | ADA Code: D2750 | Usual Fee1: $1139.00 | With Plan2: $663 | You Save: $476 | Saving Percentage: 42% |
Single crown - porcelain on noble metal | ADA Code: D2752 | Usual Fee1: $1029.00 | With Plan2: $644 | You Save: $385 | Saving Percentage: 37% |
Core build-up with pins | ADA Code: D2950 | Usual Fee1: $285.00 | With Plan2: $121 | You Save: $164 | Saving Percentage: 58% |
Labial veneer (resin laminate) - direct | ADA Code: D2960 | Usual Fee1: $650.00 | With Plan2: $183 | You Save: $467 | Saving Percentage: 72% |
Labial veneer (porcelain laminate) - indirect | ADA Code: D2962 | Usual Fee1: $1345.00 | With Plan2: $473 | You Save: $872 | Saving Percentage: 65% |
Root canal treatment - front tooth | ADA Code: D3310 | Usual Fee1: $789.00 | With Plan2: $351 | You Save: $438 | Saving Percentage: 56% |
Root canal treatment - bicuspid | ADA Code: D3320 | Usual Fee1: $937.00 | With Plan2: $441 | You Save: $496 | Saving Percentage: 53% |
Root canal treatment - molar | ADA Code: D3330 | Usual Fee1: $1195.00 | With Plan2: $607 | You Save: $588 | Saving Percentage: 49% |
Bone replacement graft - retained natural tooth - first site in quadrant | ADA Code: D4263 | Usual Fee1: $353.00 | With Plan2: $265 | You Save: $88 | Saving Percentage: 25% |
Perio scaling and root planing (per quadrant) | ADA Code: D4341 | Usual Fee1: $277.00 | With Plan2: $124 | You Save: $153 | Saving Percentage: 55% |
Regular cleaning following periodontic procedure | ADA Code: D4910 | Usual Fee1: $150.00 | With Plan2: $55 | You Save: $95 | Saving Percentage: 63% |
Full upper denture | ADA Code: D5110 | Usual Fee1: $1532.00 | With Plan2: $772 | You Save: $760 | Saving Percentage: 50% |
Full lower denture | ADA Code: D5120 | Usual Fee1: $1500.00 | With Plan2: $772 | You Save: $728 | Saving Percentage: 49% |
Add clasp to existing partial denture | ADA Code: D5660 | Usual Fee1: $261.00 | With Plan2: $134 | You Save: $127 | Saving Percentage: 49% |
Surgical placement of implant body: endosteal implant | ADA Code: D6010 | Usual Fee1: $2150.00 | With Plan2: $1,447 | You Save: $703 | Saving Percentage: 33% |
Abutment supported cast metal crown (predominantly base metal) | ADA Code: D6063 | Usual Fee1: $1259.00 | With Plan2: $694 | You Save: $565 | Saving Percentage: 45% |
Implant supported crown high noble alloys | ADA Code: D6067 | Usual Fee1: $1418.00 | With Plan2: $780 | You Save: $638 | Saving Percentage: 45% |
Tooth replacement part of permanent bridge | ADA Code: D6210 | Usual Fee1: $1098.00 | With Plan2: $591 | You Save: $507 | Saving Percentage: 46% |
Single tooth removal - simple extraction | ADA Code: D7140 | Usual Fee1: $174.00 | With Plan2: $66 | You Save: $108 | Saving Percentage: 62% |
Extraction - impacted wisdom tooth (soft tissue) | ADA Code: D7220 | Usual Fee1: $330.00 | With Plan2: $141 | You Save: $189 | Saving Percentage: 57% |
Extraction - impacted wisdom tooth (partial bony) | ADA Code: D7230 | Usual Fee1: $415.00 | With Plan2: $205 | You Save: $210 | Saving Percentage: 51% |
Comprehensive orthodontic treatment of the transitional dentition | ADA Code: D8070 | Usual Fee1: $5562.00 | With Plan2: $3,026 | You Save: $2,536 | Saving Percentage: 46% |
Full orthodontic child treatment (braces) | ADA Code: D8080 | Usual Fee1: $5658.00 | With Plan2: $3,310 | You Save: $2,348 | Saving Percentage: 41% |
Full orthodontic adult treatment (braces) | ADA Code: D8090 | Usual Fee1: $5936.00 | With Plan2: $3,478 | You Save: $2,458 | Saving Percentage: 41% |
External bleaching – per arch – performed in office | ADA Code: D9972 | Usual Fee1: $225.00 | With Plan2: $196 | You Save: $29 | Saving Percentage: 13% |
External bleaching - per tooth | ADA Code: D9973 | Usual Fee1: $185.00 | With Plan2: $22 | You Save: $163 | Saving Percentage: 88% |
Internal bleaching - per tooth | ADA Code: D9974 | Usual Fee1: $286.00 | With Plan2: $103 | You Save: $183 | Saving Percentage: 64% |
* Savings will be 20% off usual customary rate.
Included in your Aetna Vital Savings℠ is a vision savings plan by Aetna Vision powered by EyeMed. Aetna Vision provides a simple way to reduce eye care costs by taking advantage of savings.
The Aetna Vision network gives you access to 65,000+ eye care professionals nationwide.
This includes major retailers such as:
Vision Source, Pearle Vision Centers, Target Optical, Visionworks, and more.
Description | Cost Without Aetna Vision2 | Discount Savings1 | |
---|---|---|---|
Eye Exam | $90 | $63 | 30% |
Designer Frames3 | $190 | $123.50 | 40% |
Contact Lens Exam | $120 | $105 | 12% |
Lenses – Single Vision | $270 | $189 | 30% |
Notes: