|Procedure||Average Cost*||Average Cost with Aetna Dental Access*||Member Savings|
|Periodic Oral Exam||$70||$35||$35|
|Comprehensive Oral Exam||$108||$50||$58|
|X-Ray, Intraoral–Complete Series Including Bitewing||$163||$87||$76|
|X-Ray, Bitewings– Four Films||$79||$41||$38|
|X-Ray Panoramic Film||$139||$78||$61|
|Sealant Per Tooth||$72||$37||$35|
|Filling– 1 Surface Resin (White) Filling, Front (Anterior) Tooth||$200||$101||$99|
|Crown– Porcelain Fused to High Noble Metal (i.e. gold)||$1,278||$825||$453|
|Restorative Crown – Porcelain Fused to Noble Metal||$1,236||$790||$446|
|Root Canal Front Tooth (Anterior) Excluding Final Restoration||$860||$531||$329|
|Root Canal Premolar Tooth (Bicuspid), Excluding Final Restoration||$973||$632||$341|
|Root Canal Molar, Excluding Final Restoration||$1,189||$851||$338|
|Scaling/Root Planing Four or More Contiguous Teeth||$272||$162||$110|
|Periodontal Maintenance For Patients Who Have Been Previously Treated For Periodontal Disease||$166||$90||$76|
|Complete Upper Denture (Maxillary)||$1,528||$1,003||$525|
|Extraction of Erupted Tooth or Exposed Root – Includes Local Anesthesia and Suturing If Needed||$219||$99||$120|
|Comprehensive Orthodontic Treatment Child||$5,991||$3,549||$2,442|
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*Actual costs and savings may vary by provider, service and geographic location. We use the average of negotiated fees from participating providers to determine the average costs, as shown on the chart. The select regional average cost represents the average fees for the procedures listed above in Los Angeles, Orlando, Chicago and New York City, as displayed in the cost of care tool as of June 2018.
The discount program provides access to the Aetna Dental Access® network. This network is administered by Aetna Life Insurance Company (ALIC). Neither ALIC nor any of its affiliates offers or administers the discount program. Neither ALIC nor any of its affiliates is an affiliate, agent, representative or employee of discount program. Dental providers are independent contractors and not employees or agents of ALIC or its affiliates. ALIC does not provide dental care or treatment and is not responsible for outcomes.
*** If you are looking for a specific dental procedure that is not on this sample, please contact our 1020RX Member Services Center toll-free at 1-800-7-1020RX with the specific ADA Code of the procedure and we can assist with providing the discounted fee information.