Procedure | ADA Code | Usual Fee1 | With Plan2 | You Save | % Saved |
---|---|---|---|---|---|
Routine 6 month check-up | ADA Code: D0120 | Usual Fee1: $56.00 | With Plan2: $30 | You Save: $26 | Saving Percentage: 46% |
In depth check-up | ADA Code: D0150 | Usual Fee1: $98.00 | With Plan2: $59 | You Save: $39 | Saving Percentage: 40% |
Full mouth x-rays | ADA Code: D0210 | Usual Fee1: $148.00 | With Plan2: $83 | You Save: $65 | Saving Percentage: 44% |
Four bitewing x-rays | ADA Code: D0274 | Usual Fee1: $70.00 | With Plan2: $31 | You Save: $39 | Saving Percentage: 56% |
Panoramic film | ADA Code: D0330 | Usual Fee1: $125.00 | With Plan2: $69 | You Save: $56 | Saving Percentage: 45% |
Adult teeth cleaning | ADA Code: D1110 | Usual Fee1: $99.00 | With Plan2: $60 | You Save: $39 | Saving Percentage: 39% |
Child teeth cleaning | ADA Code: D1120 | Usual Fee1: $76.00 | With Plan2: $43 | You Save: $33 | Saving Percentage: 43% |
Protective sealant / tooth | ADA Code: D1351 | Usual Fee1: $60.00 | With Plan2: $28 | You Save: $32 | Saving Percentage: 53% |
1 surface silver filling for primary or permanent tooth | ADA Code: D2140 | Usual Fee1: $180.00 | With Plan2: $77 | You Save: $103 | Saving Percentage: 57% |
1 surface white filling for u or l front tooth | ADA Code: D2330 | Usual Fee1: $195.00 | With Plan2: $86 | You Save: $109 | Saving Percentage: 56% |
Single crown - porcelain on high noble metal | ADA Code: D2750 | Usual Fee1: $1265.00 | With Plan2: $765 | You Save: $500 | Saving Percentage: 40% |
Single crown - porcelain on noble metal | ADA Code: D2752 | Usual Fee1: $1435.00 | With Plan2: $741 | You Save: $694 | Saving Percentage: 48% |
Core build-up with pins | ADA Code: D2950 | Usual Fee1: $300.00 | With Plan2: $153 | You Save: $147 | Saving Percentage: 49% |
Labial veneer (resin laminate) - direct | ADA Code: D2960 | Usual Fee1: $730.00 | With Plan2: $304 | You Save: $426 | Saving Percentage: 58% |
Labial veneer (porcelain laminate) - indirect | ADA Code: D2962 | Usual Fee1: $1489.00 | With Plan2: $565 | You Save: $924 | Saving Percentage: 62% |
Root canal treatment - front tooth | ADA Code: D3310 | Usual Fee1: $1015.00 | With Plan2: $452 | You Save: $563 | Saving Percentage: 55% |
Root canal treatment - bicuspid | ADA Code: D3320 | Usual Fee1: $1151.00 | With Plan2: $497 | You Save: $654 | Saving Percentage: 57% |
Root canal treatment - molar | ADA Code: D3330 | Usual Fee1: $1395.00 | With Plan2: $705 | You Save: $690 | Saving Percentage: 49% |
Bone replacement graft - retained natural tooth - first site in quadrant | ADA Code: D4263 | Usual Fee1: $600.00 | With Plan2: $332 | You Save: $268 | Saving Percentage: 45% |
Perio scaling and root planing (per quadrant) | ADA Code: D4341 | Usual Fee1: $289.00 | With Plan2: $155 | You Save: $134 | Saving Percentage: 46% |
Regular cleaning following periodontic procedure | ADA Code: D4910 | Usual Fee1: $150.00 | With Plan2: $76 | You Save: $74 | Saving Percentage: 49% |
Full upper denture | ADA Code: D5110 | Usual Fee1: $1975.00 | With Plan2: $888 | You Save: $1,087 | Saving Percentage: 55% |
Full lower denture | ADA Code: D5120 | Usual Fee1: $1988.00 | With Plan2: $888 | You Save: $1,100 | Saving Percentage: 55% |
Add clasp to existing partial denture | ADA Code: D5660 | Usual Fee1: $237.00 | With Plan2: $124 | You Save: $113 | Saving Percentage: 48% |
Surgical placement of implant body: endosteal implant | ADA Code: D6010 | Usual Fee1: $2086.00 | With Plan2: $1,533 | You Save: $553 | Saving Percentage: 27% |
Abutment supported cast metal crown (predominantly base metal) | ADA Code: D6063 | Usual Fee1: $1338.00 | With Plan2: $675 | You Save: $663 | Saving Percentage: 50% |
Implant supported crown high noble alloys | ADA Code: D6067 | Usual Fee1: $1638.00 | With Plan2: $938 | You Save: $700 | Saving Percentage: 43% |
Tooth replacement part of permanent bridge | ADA Code: D6210 | Usual Fee1: $1400.00 | With Plan2: $694 | You Save: $706 | Saving Percentage: 50% |
Single tooth removal - simple extraction | ADA Code: D7140 | Usual Fee1: $215.00 | With Plan2: $83 | You Save: $132 | Saving Percentage: 61% |
Extraction - impacted wisdom tooth (soft tissue) | ADA Code: D7220 | Usual Fee1: $402.00 | With Plan2: $198 | You Save: $204 | Saving Percentage: 51% |
Extraction - impacted wisdom tooth (partial bony) | ADA Code: D7230 | Usual Fee1: $484.00 | With Plan2: $250 | You Save: $234 | Saving Percentage: 48% |
Comprehensive orthodontic treatment of the transitional dentition | ADA Code: D8070 | Usual Fee1: $5562.00 | With Plan2: $3,241 | You Save: $2,321 | Saving Percentage: 42% |
Full orthodontic child treatment (braces) | ADA Code: D8080 | Usual Fee1: $5658.00 | With Plan2: $3,528 | You Save: $2,130 | Saving Percentage: 38% |
Full orthodontic adult treatment (braces) | ADA Code: D8090 | Usual Fee1: $5936.00 | With Plan2: $3,706 | You Save: $2,230 | Saving Percentage: 38% |
External bleaching - per tooth | ADA Code: D9973 | Usual Fee1: $185.00 | With Plan2: $33 | You Save: $152 | Saving Percentage: 82% |
Internal bleaching - per tooth | ADA Code: D9974 | Usual Fee1: $250.00 | With Plan2: $166 | You Save: $84 | Saving Percentage: 34% |
* 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: