|Procedure||ADA Code||Fee*||With Aetna**||You Save||%|
|Routine 6 Month Check-up||ADA Code: D0120||Usual Fee*: $73.50||With Aetna**: $24.75||You Save: $48.75||Saving Percentage: 66%|
|Full Mouth X-Rays||ADA Code: D0210||Usual Fee*: $171.50||With Aetna**: $66.50||You Save: $105.00||Saving Percentage: 61%|
|Adult Teeth Cleaning||ADA Code: D1110||Usual Fee*: $125.00||With Aetna**: $53.00||You Save: $72.00||Saving Percentage: 58%|
|Child Teeth Cleaning||ADA Code: D1120||Usual Fee*: $91.00||With Aetna**: $37.50||You Save: $53.50||Saving Percentage: 59%|
|Perio Scaling and Root Planing (Per Quadrant)||ADA Code: D4341||Usual Fee*: $289.75||With Aetna**: $137.75||You Save: $152.00||Saving Percentage: 52%|
|1 Surface Silver Filling for Primary or Permanent Tooth||ADA Code: D2140||Usual Fee*: $198.75||With Aetna**: Call||You Save: Call||Saving Percentage: Call|
|1 Surface White Filling for U or L Front Tooth||ADA Code: D2330||Usual Fee*: $222.75||With Aetna**: $83.50||You Save: $139.25||Saving Percentage: 63%|
|Root Canal Treatment – Front Tooth||ADA Code: D3310||Usual Fee*: $1,060.75||With Aetna**: $392.25||You Save: $668.50||Saving Percentage: 63%|
|Root Canal Treatment – Bicuspid||ADA Code: D3320||Usual Fee*: $1,169.25||With Aetna**: $463.75||You Save: $705.50||Saving Percentage: 60%|
|Root Canal Treatment – Molar||ADA Code: D3330||Usual Fee*: $1,490.50||With Aetna**: $652.50||You Save: $838.00||Saving Percentage: 56%|
|Full Upper Denture||ADA Code: D5110||Usual Fee*: $1,932.50||With Aetna**: $879.00||You Save: $1,053.50||Saving Percentage: 55%|
|Single Tooth Extraction||ADA Code: D7140||Usual Fee*: $267.00||With Aetna**: $74.25||You Save: $193.25||Saving Percentage: 72%|
|Wisdom Tooth Extraction (Impacted Tooth, Soft Tissue)||ADA Code: D7220||Usual Fee*: $443.00||With Aetna**: Call||You Save: Call||Saving Percentage: Call|
Discounted fees are listed for visits to a participating general dentist. Actual costs and savings may vary by provider, service and geographic location. The discounted fee represents the average cost of the negotiated fees for Tampa, Dallas, Chicago and New York City. Individual dentist fee schedules may differ. In order to determine the specific rates for a dental provider, you should contact the dental provider directly.
Savings on vision and hearing care, and prescription drug medications are also included in the Aetna Vital Dental Savings’ Plus Rx. Click on the tabs below for an explanation of added savings for these services.
Included in your Aetna Vital Dental Savings℠ Plus Rx 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.
Aetna Vision – eye exams, lenses, frames and more
The Aetna Vision network gives you access to 65,000+ eye care professionals nationwide.
This includes major retailers such as:
JCPenney Optical, Vision Source, Pearle Vision Centers, Sears Optical, Target Optical, Visionworks, and more.
|Description||Cost Without Aetna Vision2||Typical Savings|
|Contact Lens Exam||$120||$105||12%|
|Lenses – Single Vision||$270||$289||30%|
Included in your Aetna Vital Dental Savings℠ Plus Rx membership is a prescription drug benefit, which will provide you access to savings regarding your prescription medication needs.
Aetna RX – access to savings on most FDA-approved prescription medications and more.
The Aetna RX prescription savings program boasts a large pharmacy discount network with 68,000+ well-known retail pharmacies nationwide such as: Costco, CVS, Walgreens, Rite Aid, Safeway, Publix Pharmacy, Walmart, Sam’s Club and more.
This program provides instant savings when filling your prescription medication through a participating pharmacy or through the convenient mail order service.
|Description||Amount||Cost with Plan|
|Lipitor 20 mg||30 tabs||$137||$23|
|Prevacid 30 mg||30 caps||$189||$23|
|Nexium 40 mg||30 caps||$186||$30|
|Sertraline 50 mg||30 tabs||$89||$75|
|Zocor 20 mg||30 tabs||$168||$13|
|Zoloft 50 mg||30 tabs||$116||$21|
*Based on AWP price as reported by Medispan on February 2013.
Included in your Aetna Vital Dental Savings℠ Plus Rx membership is a hearing benefit through Amplifon, which will provide you access to savings regarding your hearing care needs including exams, hearing aids, and other hearing care services.
Amplifon – access to one of largest hearing providers in the country with savings on a variety of hearing aids and services and more
The Amplifon hearing program provides savings on hearing exams and services at more than 4,600 locations nationwide, and offers deep discounts on hearing aid brands such as:
Oticon, Phonak, ReSound, Rexton, Starkey, Miracle-Ear, Sonic, Siemens, Unitron, and more.
This program provides instant savings on diagnostic services, including hearing exams, services and select hearing health products.
*Depending upon provider. Some providers may charge a $48 fee
|Siemens Hearing Aid Premier||$3,400||$1,900||44%|
|Siemens Hearing Aid Economy||$1,595||$695||56%|
|1*Cost per ear|