| Procedure | Average Cost* | Average Cost with Aetna Dental Access* | Member Savings |
|---|---|---|---|
| Periodic Oral Exam | $76 | $35 | $41 |
| Comprehensive Oral Exam | $116 | $51 | $65 |
| X-Ray, Intraoral–Complete Series Including Bitewing | $174 | $89 | $85 |
| X-Ray, Bitewings– Four Films | $85 | $42 | $43 |
| X-Ray Panoramic Film | $148 | $76 | $72 |
| Cleaning (Prophylaxis)–Adult | $130 | $69 | $61 |
| Cleaning (Prophylaxis)–Child | $96 | $53 | $43 |
| Topical Application of Fluoride | $50 | $26 | $24 |
| Sealant Per Tooth | $76 | $37 | $39 |
| Filling (Amalgam)– 1 Surface Resin (White) Filling, Front (Anterior) Tooth |
$211 | $104 | $107 |
| Crown- Porcelain Fused to High Nobel Metal (i.e. gold) | $1,351 | $819 | $532 |
| Restorative Crown- Porcelain Fused to Nobel Metal | $1,348 | $793 | $555 |
| Scaling/Root Planing Four or More Contiguous Teeth | $284 | $164 | $120 |
| Periodontal Maintenance For Patients Who Have Been Previously Treated For Periodontal Disease | $176 | $92 | $84 |
| Extraction of Erupted Tooth or Exposed Root - Includes Local Anesthesia and Suturing If Needed | $236 | $104 | $132 |
| Comprehensive Orthodontic Treatment Child | $5,975 | $3,481 | $2,494 |
| General Anesthesia | $272 | $162 | $110 |
| IV Sedation/Analgesia | $241 | $134 | $107 |
| Occlusal Guard – Hard Appliance, Full Arch | $679 | $400 | $279 |
*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. 1 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 September 2021.