Procedure | ADA Code | Usual Fee1 | With Plan2 | You Save | % Saved |
---|---|---|---|---|---|
Routine 6 month check-up | ADA Code: D0120 | Usual Fee1: $55.00 | With Plan2: $27 | You Save: $28 | Saving Percentage: 51% |
In depth check-up | ADA Code: D0150 | Usual Fee1: $81.00 | With Plan2: $39 | You Save: $42 | Saving Percentage: 52% |
Full mouth x-rays | ADA Code: D0210 | Usual Fee1: $138.00 | With Plan2: $65 | You Save: $73 | Saving Percentage: 53% |
Four bitewing x-rays | ADA Code: D0274 | Usual Fee1: $62.00 | With Plan2: $31 | You Save: $31 | Saving Percentage: 50% |
Panoramic film | ADA Code: D0330 | Usual Fee1: $116.00 | With Plan2: $51 | You Save: $65 | Saving Percentage: 56% |
Adult teeth cleaning | ADA Code: D1110 | Usual Fee1: $89.00 | With Plan2: $50 | You Save: $39 | Saving Percentage: 44% |
Child teeth cleaning | ADA Code: D1120 | Usual Fee1: $72.00 | With Plan2: $36 | You Save: $36 | Saving Percentage: 50% |
Protective sealant / tooth | ADA Code: D1351 | Usual Fee1: $53.00 | With Plan2: $25 | You Save: $28 | Saving Percentage: 53% |
1 surface silver filling for primary or permanent tooth | ADA Code: D2140 | Usual Fee1: $139.00 | With Plan2: $60 | You Save: $79 | Saving Percentage: 57% |
1 surface white filling for u or l front tooth | ADA Code: D2330 | Usual Fee1: $151.00 | With Plan2: $79 | You Save: $72 | Saving Percentage: 48% |
Single crown - porcelain on high noble metal | ADA Code: D2750 | Usual Fee1: $1054.00 | With Plan2: $709 | You Save: $345 | Saving Percentage: 33% |
Single crown - porcelain on noble metal | ADA Code: D2752 | Usual Fee1: $938.00 | With Plan2: $690 | You Save: $248 | Saving Percentage: 26% |
Core build-up with pins | ADA Code: D2950 | Usual Fee1: $264.00 | With Plan2: $134 | You Save: $130 | Saving Percentage: 49% |
Labial veneer (resin laminate) - direct | ADA Code: D2960 | Usual Fee1: $370.00 | With Plan2: $212 | You Save: $158 | Saving Percentage: 43% |
Labial veneer (porcelain laminate) - indirect | ADA Code: D2962 | Usual Fee1: $1010.00 | With Plan2: $497 | You Save: $513 | Saving Percentage: 51% |
Root canal treatment - front tooth | ADA Code: D3310 | Usual Fee1: $756.00 | With Plan2: $355 | You Save: $401 | Saving Percentage: 53% |
Root canal treatment - bicuspid | ADA Code: D3320 | Usual Fee1: $884.00 | With Plan2: $484 | You Save: $400 | Saving Percentage: 45% |
Root canal treatment - molar | ADA Code: D3330 | Usual Fee1: $1016.00 | With Plan2: $632 | You Save: $384 | Saving Percentage: 38% |
Bone replacement graft - retained natural tooth - first site in quadrant | ADA Code: D4263 | Usual Fee1: $650.00 | With Plan2: $351 | You Save: $299 | Saving Percentage: 46% |
Perio scaling and root planing (per quadrant) | ADA Code: D4341 | Usual Fee1: $254.00 | With Plan2: $136 | You Save: $118 | Saving Percentage: 46% |
Regular cleaning following periodontic procedure | ADA Code: D4910 | Usual Fee1: $130.00 | With Plan2: $67 | You Save: $63 | Saving Percentage: 48% |
Full upper denture | ADA Code: D5110 | Usual Fee1: $1515.00 | With Plan2: $847 | You Save: $668 | Saving Percentage: 44% |
Full lower denture | ADA Code: D5120 | Usual Fee1: $1500.00 | With Plan2: $847 | You Save: $653 | Saving Percentage: 44% |
Add clasp to existing partial denture | ADA Code: D5660 | Usual Fee1: $208.00 | With Plan2: $157 | You Save: $51 | Saving Percentage: 25% |
Surgical placement of implant body: endosteal implant | ADA Code: D6010 | Usual Fee1: $2073.00 | With Plan2: $1,532 | You Save: $541 | Saving Percentage: 26% |
Abutment supported cast metal crown (predominantly base metal) | ADA Code: D6063 | Usual Fee1: $1111.00 | With Plan2: $716 | You Save: $395 | Saving Percentage: 36% |
Implant supported crown high noble alloys | ADA Code: D6067 | Usual Fee1: $1251.00 | With Plan2: $830 | You Save: $421 | Saving Percentage: 34% |
Tooth replacement part of permanent bridge | ADA Code: D6210 | Usual Fee1: $978.00 | With Plan2: $633 | You Save: $345 | Saving Percentage: 35% |
Single tooth removal - simple extraction | ADA Code: D7140 | Usual Fee1: $168.00 | With Plan2: $70 | You Save: $98 | Saving Percentage: 58% |
Extraction - impacted wisdom tooth (soft tissue) | ADA Code: D7220 | Usual Fee1: $278.00 | With Plan2: $196 | You Save: $82 | Saving Percentage: 29% |
Extraction - impacted wisdom tooth (partial bony) | ADA Code: D7230 | Usual Fee1: $362.00 | With Plan2: $227 | You Save: $135 | Saving Percentage: 37% |
Comprehensive orthodontic treatment of the transitional dentition | ADA Code: D8070 | Usual Fee1: $5562.00 | With Plan2: $3,247 | You Save: $2,315 | Saving Percentage: 42% |
Full orthodontic child treatment (braces) | ADA Code: D8080 | Usual Fee1: $5658.00 | With Plan2: $3,537 | You Save: $2,121 | Saving Percentage: 37% |
Full orthodontic adult treatment (braces) | ADA Code: D8090 | Usual Fee1: $5936.00 | With Plan2: $3,715 | You Save: $2,221 | Saving Percentage: 37% |
External bleaching – per arch – performed in office | ADA Code: D9972 | Usual Fee1: $225.00 | With Plan2: $222 | You Save: $3 | Saving Percentage: 1% |
External bleaching - per tooth | ADA Code: D9973 | Usual Fee1: $185.00 | With Plan2: $25 | You Save: $160 | Saving Percentage: 86% |
Internal bleaching - per tooth | ADA Code: D9974 | Usual Fee1: $140.00 | With Plan2: $118 | You Save: $22 | Saving Percentage: 16% |
* 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: