Procedure | ADA Code | Usual Fee1 | With Plan2 | You Save | % Saved |
---|---|---|---|---|---|
Routine 6 month check-up | ADA Code: D0120 | Usual Fee1: $53.00 | With Plan2: $27 | You Save: $26 | Saving Percentage: 49% |
In depth check-up | ADA Code: D0150 | Usual Fee1: $92.00 | With Plan2: $40 | You Save: $52 | Saving Percentage: 57% |
Full mouth x-rays | ADA Code: D0210 | Usual Fee1: $145.00 | With Plan2: $67 | You Save: $78 | Saving Percentage: 54% |
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: $128.00 | With Plan2: $56 | You Save: $72 | Saving Percentage: 56% |
Adult teeth cleaning | ADA Code: D1110 | Usual Fee1: $92.00 | With Plan2: $51 | You Save: $41 | Saving Percentage: 45% |
Child teeth cleaning | ADA Code: D1120 | Usual Fee1: $70.00 | With Plan2: $37 | You Save: $33 | Saving Percentage: 47% |
Protective sealant / tooth | ADA Code: D1351 | Usual Fee1: $56.00 | With Plan2: $30 | You Save: $26 | Saving Percentage: 46% |
1 surface silver filling for primary or permanent tooth | ADA Code: D2140 | Usual Fee1: $160.00 | With Plan2: $73 | You Save: $87 | Saving Percentage: 54% |
1 surface white filling for u or l front tooth | ADA Code: D2330 | Usual Fee1: $163.00 | With Plan2: $87 | You Save: $76 | Saving Percentage: 47% |
Single crown - porcelain on high noble metal | ADA Code: D2750 | Usual Fee1: $1150.00 | With Plan2: $735 | You Save: $415 | Saving Percentage: 36% |
Single crown - porcelain on noble metal | ADA Code: D2752 | Usual Fee1: $1300.00 | With Plan2: $711 | You Save: $589 | Saving Percentage: 45% |
Core build-up with pins | ADA Code: D2950 | Usual Fee1: $293.00 | With Plan2: $133 | You Save: $160 | Saving Percentage: 55% |
Labial veneer (resin laminate) - direct | ADA Code: D2960 | Usual Fee1: $602.00 | With Plan2: $244 | You Save: $358 | Saving Percentage: 59% |
Labial veneer (porcelain laminate) - indirect | ADA Code: D2962 | Usual Fee1: $1350.00 | With Plan2: $539 | You Save: $811 | Saving Percentage: 60% |
Root canal treatment - front tooth | ADA Code: D3310 | Usual Fee1: $945.00 | With Plan2: $429 | You Save: $516 | Saving Percentage: 55% |
Root canal treatment - bicuspid | ADA Code: D3320 | Usual Fee1: $1020.00 | With Plan2: $472 | You Save: $548 | Saving Percentage: 54% |
Root canal treatment - molar | ADA Code: D3330 | Usual Fee1: $1200.00 | With Plan2: $663 | You Save: $537 | Saving Percentage: 45% |
Bone replacement graft - retained natural tooth - first site in quadrant | ADA Code: D4263 | Usual Fee1: $490.00 | With Plan2: $289 | You Save: $201 | Saving Percentage: 41% |
Perio scaling and root planing (per quadrant) | ADA Code: D4341 | Usual Fee1: $265.00 | With Plan2: $147 | You Save: $118 | Saving Percentage: 45% |
Regular cleaning following periodontic procedure | ADA Code: D4910 | Usual Fee1: $150.00 | With Plan2: $64 | You Save: $86 | Saving Percentage: 57% |
Full upper denture | ADA Code: D5110 | Usual Fee1: $1750.00 | With Plan2: $850 | You Save: $900 | Saving Percentage: 51% |
Full lower denture | ADA Code: D5120 | Usual Fee1: $1742.00 | With Plan2: $850 | You Save: $892 | Saving Percentage: 51% |
Add clasp to existing partial denture | ADA Code: D5660 | Usual Fee1: $273.00 | With Plan2: $164 | You Save: $109 | Saving Percentage: 40% |
Surgical placement of implant body: endosteal implant | ADA Code: D6010 | Usual Fee1: $2135.00 | With Plan2: $1,532 | You Save: $603 | Saving Percentage: 28% |
Abutment supported cast metal crown (predominantly base metal) | ADA Code: D6063 | Usual Fee1: $1531.00 | With Plan2: $568 | You Save: $963 | Saving Percentage: 63% |
Implant supported crown high noble alloys | ADA Code: D6067 | Usual Fee1: $1724.00 | With Plan2: $856 | You Save: $868 | Saving Percentage: 50% |
Tooth replacement part of permanent bridge | ADA Code: D6210 | Usual Fee1: $1208.00 | With Plan2: $650 | You Save: $558 | Saving Percentage: 46% |
Single tooth removal - simple extraction | ADA Code: D7140 | Usual Fee1: $182.00 | With Plan2: $72 | You Save: $110 | Saving Percentage: 60% |
Extraction - impacted wisdom tooth (soft tissue) | ADA Code: D7220 | Usual Fee1: $326.00 | With Plan2: $153 | You Save: $173 | Saving Percentage: 53% |
Extraction - impacted wisdom tooth (partial bony) | ADA Code: D7230 | Usual Fee1: $415.00 | With Plan2: $219 | You Save: $196 | Saving Percentage: 47% |
Comprehensive orthodontic treatment of the transitional dentition | ADA Code: D8070 | Usual Fee1: $5562.00 | With Plan2: $3,174 | You Save: $2,388 | Saving Percentage: 43% |
Full orthodontic child treatment (braces) | ADA Code: D8080 | Usual Fee1: $5658.00 | With Plan2: $3,441 | You Save: $2,217 | Saving Percentage: 39% |
Full orthodontic adult treatment (braces) | ADA Code: D8090 | Usual Fee1: $5936.00 | With Plan2: $3,616 | You Save: $2,320 | Saving Percentage: 39% |
External bleaching – per arch – performed in office | ADA Code: D9972 | Usual Fee1: $295.00 | With Plan2: $209 | You Save: $86 | Saving Percentage: 29% |
External bleaching - per tooth | ADA Code: D9973 | Usual Fee1: $185.00 | With Plan2: $24 | You Save: $161 | Saving Percentage: 87% |
Internal bleaching - per tooth | ADA Code: D9974 | Usual Fee1: $300.00 | With Plan2: $111 | You Save: $189 | Saving Percentage: 63% |
* 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: