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% |
The sample table above is a small selection of common procedures discounted by Aetna Vital Savings℠ Plus. The procedures discounted under Vital Savings by Aetna offer similar savings to the sample 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 the average fee information currently available on our systems. Individual dentist fee schedules may differ. Vital Savings by 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.
1 The [“Usual Fee”] is determined by DentalPlans.com, Inc., using benchmark data from FAIR Health, Inc. FAIR Health data is used under license. Fees may reflect combined fees from several different procedures into one procedure and may not be directly comparable to a specific benchmark in FAIR Health Data. Actual fees charged by your provider may vary for a variety of reasons.
2 Discounted fees are listed for visits to a participating general dentist. Members will be charged the provider's Vital Savings by Aetna contracted fees. Charges may vary from the sample fee schedule above. Consult with your provider prior to beginning any treatment. Lab fees may be additional.
This plan is based geographically by ZIP code in terms of provider participation and location. Fee schedules and savings may vary by ZIP code and by Provider within a ZIP code.
* Savings will be 20% off usual customary rate.
Savings on vision and hearing care, and prescription drug medications are also included in the Aetna Vital Savings℠ Plus. Click on the tabs below for an explanation of added savings for these services.
Included in your Aetna Vital Savings℠ Plus 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 | Typical Savings | |
---|---|---|---|
Eye Exam | $90 | $63 | 30% |
Designer Frames3 | $190 | $123.50 | 40% |
Contact Lens Exam | $120 | $105 | 12% |
Lenses – Single Vision | $270 | $189 | 30% |
Notes:
Included in your Aetna Vital Savings℠ Plus membership is a prescription drug benefit, which will provide you access to savings regarding your prescription medication needs.
The Aetna RX prescription savings program boasts a large pharmacy discount network with 65,000+ well-known retail pharmacies nationwide such as: Costco, Walgreens, Rite Aid, Safeway, Publix Pharmacy, Walmart, Sam’s Club and more.
This program provides instant savings when filling your prescription medication through a participating pharmacy.
Description | Amount |
---|---|
Amoxicillin 500mg | 21 tabs |
Lisinopril 5mg | 30 tabs |
Norvasc 5mg | 30 tabs |
*Cost may vary by State, Location, and date dispensed.
Included in your Aetna Vital Savings℠ Plus membership is a hearing benefit through Amplifon, which will provide you access to savings regarding your hearing care needs including exams, hearing aids, and other hearing care services.
Amplifon – access to one of largest hearing providers in the country with savings on a variety of hearing aids and services and more
The Amplifon hearing program provides savings on hearing exams and services at more than 4,600 locations nationwide, and offers deep discounts on hearing aid brands such as: Oticon, Phonak, ReSound, Rexton, Starkey, Miracle-Ear, Sonic, Siemens, Unitron, and more.
This program provides instant savings on diagnostic services, including hearing exams, services and select hearing health products.
*Depending upon provider. Some providers may charge a $48 fee
Description | Discount | |||
---|---|---|---|---|
Siemens Hearing Aid Premier | $3,400 | $1,900 | 44% | |
Siemens Hearing Aid Economy | $1,595 | $695 | 56% | |
1*Cost per ear |