Procedure | ADA Code | Usual Fee1 | With Plan2 | You Save | % Saved |
---|---|---|---|---|---|
Routine 6 month check-up | ADA Code: D0120 | Usual Fee1: $69.00 | With Plan2: $33 | You Save: $36 | Saving Percentage: 52% |
In depth check-up | ADA Code: D0150 | Usual Fee1: $106.00 | With Plan2: $43 | You Save: $63 | Saving Percentage: 59% |
Full mouth x-rays | ADA Code: D0210 | Usual Fee1: $160.00 | With Plan2: $80 | You Save: $80 | Saving Percentage: 50% |
Four bitewing x-rays | ADA Code: D0274 | Usual Fee1: $75.00 | With Plan2: $40 | You Save: $35 | Saving Percentage: 47% |
Panoramic film | ADA Code: D0330 | Usual Fee1: $125.00 | With Plan2: $65 | You Save: $60 | Saving Percentage: 48% |
Adult teeth cleaning | ADA Code: D1110 | Usual Fee1: $108.00 | With Plan2: $65 | You Save: $43 | Saving Percentage: 40% |
Child teeth cleaning | ADA Code: D1120 | Usual Fee1: $85.00 | With Plan2: $50 | You Save: $35 | Saving Percentage: 41% |
Protective sealant / tooth | ADA Code: D1351 | Usual Fee1: $69.00 | With Plan2: $26 | You Save: $43 | Saving Percentage: 62% |
1 surface silver filling for primary or permanent tooth | ADA Code: D2140 | Usual Fee1: $192.00 | With Plan2: $77 | You Save: $115 | Saving Percentage: 60% |
1 surface white filling for u or l front tooth | ADA Code: D2330 | Usual Fee1: $210.00 | With Plan2: $95 | You Save: $115 | Saving Percentage: 55% |
Single crown - porcelain on high noble metal | ADA Code: D2750 | Usual Fee1: $1215.00 | With Plan2: $737 | You Save: $478 | Saving Percentage: 39% |
Single crown - porcelain on noble metal | ADA Code: D2752 | Usual Fee1: $1050.00 | With Plan2: $714 | You Save: $336 | Saving Percentage: 32% |
Core build-up with pins | ADA Code: D2950 | Usual Fee1: $295.00 | With Plan2: $139 | You Save: $156 | Saving Percentage: 53% |
Labial veneer (resin laminate) - direct | ADA Code: D2960 | Usual Fee1: $675.00 | With Plan2: $290 | You Save: $385 | Saving Percentage: 57% |
Labial veneer (porcelain laminate) - indirect | ADA Code: D2962 | Usual Fee1: $1500.00 | With Plan2: $634 | You Save: $866 | Saving Percentage: 58% |
Root canal treatment - front tooth | ADA Code: D3310 | Usual Fee1: $949.00 | With Plan2: $423 | You Save: $526 | Saving Percentage: 55% |
Root canal treatment - bicuspid | ADA Code: D3320 | Usual Fee1: $1053.00 | With Plan2: $541 | You Save: $512 | Saving Percentage: 49% |
Root canal treatment - molar | ADA Code: D3330 | Usual Fee1: $1300.00 | With Plan2: $665 | You Save: $635 | Saving Percentage: 49% |
Bone replacement graft - retained natural tooth - first site in quadrant | ADA Code: D4263 | Usual Fee1: $850.00 | With Plan2: $290 | You Save: $560 | Saving Percentage: 66% |
Perio scaling and root planing (per quadrant) | ADA Code: D4341 | Usual Fee1: $275.00 | With Plan2: $141 | You Save: $134 | Saving Percentage: 49% |
Regular cleaning following periodontic procedure | ADA Code: D4910 | Usual Fee1: $164.00 | With Plan2: $74 | You Save: $90 | Saving Percentage: 55% |
Full upper denture | ADA Code: D5110 | Usual Fee1: $1900.00 | With Plan2: $1,022 | You Save: $878 | Saving Percentage: 46% |
Full lower denture | ADA Code: D5120 | Usual Fee1: $1850.00 | With Plan2: $1,022 | You Save: $828 | Saving Percentage: 45% |
Add clasp to existing partial denture | ADA Code: D5660 | Usual Fee1: $268.00 | With Plan2: $124 | You Save: $144 | Saving Percentage: 54% |
Surgical placement of implant body: endosteal implant | ADA Code: D6010 | Usual Fee1: $2321.00 | With Plan2: $1,503 | You Save: $818 | Saving Percentage: 35% |
Abutment supported cast metal crown (predominantly base metal) | ADA Code: D6063 | Usual Fee1: $1440.00 | With Plan2: $790 | You Save: $650 | Saving Percentage: 45% |
Implant supported crown high noble alloys | ADA Code: D6067 | Usual Fee1: $1500.00 | With Plan2: $920 | You Save: $580 | Saving Percentage: 39% |
Tooth replacement part of permanent bridge | ADA Code: D6210 | Usual Fee1: $1200.00 | With Plan2: $687 | You Save: $513 | Saving Percentage: 43% |
Single tooth removal - simple extraction | ADA Code: D7140 | Usual Fee1: $197.00 | With Plan2: $86 | You Save: $111 | Saving Percentage: 56% |
Extraction - impacted wisdom tooth (soft tissue) | ADA Code: D7220 | Usual Fee1: $368.00 | With Plan2: $180 | You Save: $188 | Saving Percentage: 51% |
Extraction - impacted wisdom tooth (partial bony) | ADA Code: D7230 | Usual Fee1: $439.00 | With Plan2: $241 | You Save: $198 | Saving Percentage: 45% |
Comprehensive orthodontic treatment of the transitional dentition | ADA Code: D8070 | Usual Fee1: $5562.00 | With Plan2: $3,534 | You Save: $2,028 | Saving Percentage: 36% |
Full orthodontic child treatment (braces) | ADA Code: D8080 | Usual Fee1: $5658.00 | With Plan2: $3,774 | You Save: $1,884 | Saving Percentage: 33% |
Full orthodontic adult treatment (braces) | ADA Code: D8090 | Usual Fee1: $5936.00 | With Plan2: $3,964 | You Save: $1,972 | Saving Percentage: 33% |
External bleaching – per arch – performed in office | ADA Code: D9972 | Usual Fee1: $399.00 | With Plan2: $323 | You Save: $76 | Saving Percentage: 19% |
External bleaching - per tooth | ADA Code: D9973 | Usual Fee1: $185.00 | With Plan2: $37 | You Save: $148 | Saving Percentage: 80% |
Internal bleaching - per tooth | ADA Code: D9974 | Usual Fee1: $350.00 | With Plan2: $170 | You Save: $180 | Saving Percentage: 51% |
* 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: