| Procedure | ADA Code | Usual Fee1 | With Plan2 | You Save | % Saved |
|---|---|---|---|---|---|
| Routine 6 month check-up | ADA Code: D0120 | Usual Fee1: $95.00 | With Plan2: $35 | You Save: $60 | Saving Percentage: 63% |
| In depth check-up | ADA Code: D0150 | Usual Fee1: $130.00 | With Plan2: $45 | You Save: $85 | Saving Percentage: 65% |
| Full mouth x-rays | ADA Code: D0210 | Usual Fee1: $179.00 | With Plan2: $81 | You Save: $98 | Saving Percentage: 55% |
| Four bitewing x-rays | ADA Code: D0274 | Usual Fee1: $114.00 | With Plan2: $33 | You Save: $81 | Saving Percentage: 71% |
| Panoramic film | ADA Code: D0330 | Usual Fee1: $151.00 | With Plan2: $64 | You Save: $87 | Saving Percentage: 58% |
| Adult teeth cleaning | ADA Code: D1110 | Usual Fee1: $119.00 | With Plan2: $64 | You Save: $55 | Saving Percentage: 46% |
| Child teeth cleaning | ADA Code: D1120 | Usual Fee1: $97.00 | With Plan2: $42 | You Save: $55 | Saving Percentage: 57% |
| Protective sealant / tooth | ADA Code: D1351 | Usual Fee1: $71.00 | With Plan2: $32 | You Save: $39 | Saving Percentage: 55% |
| 1 surface silver filling for primary or permanent tooth | ADA Code: D2140 | Usual Fee1: $162.00 | With Plan2: $67 | You Save: $95 | Saving Percentage: 59% |
| 1 surface white filling for u or l front tooth | ADA Code: D2330 | Usual Fee1: $203.00 | With Plan2: $90 | You Save: $113 | Saving Percentage: 56% |
| Single crown - porcelain on high noble metal | ADA Code: D2750 | Usual Fee1: $1338.00 | With Plan2: $833 | You Save: $505 | Saving Percentage: 38% |
| Single crown - porcelain on noble metal | ADA Code: D2752 | Usual Fee1: $1423.00 | With Plan2: $809 | You Save: $614 | Saving Percentage: 43% |
| Core build-up with pins | ADA Code: D2950 | Usual Fee1: $320.00 | With Plan2: $157 | You Save: $163 | Saving Percentage: 51% |
| Labial veneer (resin laminate) - direct | ADA Code: D2960 | Usual Fee1: $625.00 | With Plan2: $202 | You Save: $423 | Saving Percentage: 68% |
| Labial veneer (porcelain laminate) - indirect | ADA Code: D2962 | Usual Fee1: $1520.00 | With Plan2: $571 | You Save: $949 | Saving Percentage: 62% |
| Root canal treatment - front tooth | ADA Code: D3310 | Usual Fee1: $900.00 | With Plan2: $419 | You Save: $481 | Saving Percentage: 53% |
| Root canal treatment - bicuspid | ADA Code: D3320 | Usual Fee1: $1100.00 | With Plan2: $541 | You Save: $559 | Saving Percentage: 51% |
| Root canal treatment - molar | ADA Code: D3330 | Usual Fee1: $1401.00 | With Plan2: $732 | You Save: $669 | Saving Percentage: 48% |
| Bone replacement graft - retained natural tooth - first site in quadrant | ADA Code: D4263 | Usual Fee1: $662.00 | With Plan2: $338 | You Save: $324 | Saving Percentage: 49% |
| Perio scaling and root planing (per quadrant) | ADA Code: D4341 | Usual Fee1: $312.00 | With Plan2: $148 | You Save: $164 | Saving Percentage: 53% |
| Regular cleaning following periodontic procedure | ADA Code: D4910 | Usual Fee1: $165.00 | With Plan2: $76 | You Save: $89 | Saving Percentage: 54% |
| Full upper denture | ADA Code: D5110 | Usual Fee1: $2023.00 | With Plan2: $995 | You Save: $1,028 | Saving Percentage: 51% |
| Full lower denture | ADA Code: D5120 | Usual Fee1: $1827.00 | With Plan2: $995 | You Save: $832 | Saving Percentage: 46% |
| Add clasp to existing partial denture | ADA Code: D5660 | Usual Fee1: $287.00 | With Plan2: $180 | You Save: $107 | Saving Percentage: 37% |
| Surgical placement of implant body: endosteal implant | ADA Code: D6010 | Usual Fee1: $2002.00 | With Plan2: $1,539 | You Save: $463 | Saving Percentage: 23% |
| Abutment supported cast metal crown (predominantly base metal) | ADA Code: D6063 | Usual Fee1: $1597.00 | With Plan2: $685 | You Save: $912 | Saving Percentage: 57% |
| Implant supported crown high noble alloys | ADA Code: D6067 | Usual Fee1: $1547.00 | With Plan2: $958 | You Save: $589 | Saving Percentage: 38% |
| Tooth replacement part of permanent bridge | ADA Code: D6210 | Usual Fee1: $1597.00 | With Plan2: $728 | You Save: $869 | Saving Percentage: 54% |
| Single tooth removal - simple extraction | ADA Code: D7140 | Usual Fee1: $322.00 | With Plan2: $88 | You Save: $234 | Saving Percentage: 73% |
| Extraction - impacted wisdom tooth (soft tissue) | ADA Code: D7220 | Usual Fee1: $360.00 | With Plan2: $183 | You Save: $177 | Saving Percentage: 49% |
| Extraction - impacted wisdom tooth (partial bony) | ADA Code: D7230 | Usual Fee1: $535.00 | With Plan2: $232 | You Save: $303 | Saving Percentage: 57% |
| Comprehensive orthodontic treatment of the transitional dentition | ADA Code: D8070 | Usual Fee1: $4693.00 | With Plan2: $3,316 | You Save: $1,377 | Saving Percentage: 29% |
| Full orthodontic adult treatment (braces) | ADA Code: D8090 | Usual Fee1: $3825.00 | With Plan2: $3,788 | You Save: $37 | Saving Percentage: 1% |
| External bleaching – per arch – performed in office | ADA Code: D9972 | Usual Fee1: $437.00 | With Plan2: $299 | You Save: $138 | Saving Percentage: 32% |
| External bleaching - per tooth | ADA Code: D9973 | Usual Fee1: $255.00 | With Plan2: $32 | You Save: $223 | Saving Percentage: 87% |
| Internal bleaching - per tooth | ADA Code: D9974 | Usual Fee1: $440.00 | With Plan2: $160 | You Save: $280 | Saving Percentage: 64% |
* 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: