Procedure | ADA Code | Usual Fee1 | With Plan2 | You Save | % Saved |
---|---|---|---|---|---|
Routine 6 month check-up | ADA Code: D0120 | Usual Fee1: $51.00 | With Plan2: $20 | You Save: $31 | Saving Percentage: 61% |
In depth check-up | ADA Code: D0150 | Usual Fee1: $86.00 | With Plan2: $29 | You Save: $57 | Saving Percentage: 66% |
Full mouth x-rays | ADA Code: D0210 | Usual Fee1: $143.00 | With Plan2: $57 | You Save: $86 | Saving Percentage: 60% |
Four bitewing x-rays | ADA Code: D0274 | Usual Fee1: $66.00 | With Plan2: $25 | You Save: $41 | Saving Percentage: 62% |
Panoramic film | ADA Code: D0330 | Usual Fee1: $115.00 | With Plan2: $44 | You Save: $71 | Saving Percentage: 62% |
Adult teeth cleaning | ADA Code: D1110 | Usual Fee1: $90.00 | With Plan2: $44 | You Save: $46 | Saving Percentage: 51% |
Child teeth cleaning | ADA Code: D1120 | Usual Fee1: $66.00 | With Plan2: $30 | You Save: $36 | Saving Percentage: 55% |
Protective sealant / tooth | ADA Code: D1351 | Usual Fee1: $56.00 | With Plan2: $25 | You Save: $31 | Saving Percentage: 55% |
1 surface silver filling for primary or permanent tooth | ADA Code: D2140 | Usual Fee1: $149.00 | With Plan2: $44 | You Save: $105 | Saving Percentage: 70% |
1 surface white filling for u or l front tooth | ADA Code: D2330 | Usual Fee1: $160.00 | With Plan2: $58 | You Save: $102 | Saving Percentage: 64% |
Single crown - porcelain on high noble metal | ADA Code: D2750 | Usual Fee1: $1139.00 | With Plan2: $563 | You Save: $576 | Saving Percentage: 51% |
Single crown - porcelain on noble metal | ADA Code: D2752 | Usual Fee1: $1029.00 | With Plan2: $517 | You Save: $512 | Saving Percentage: 50% |
Core build-up with pins | ADA Code: D2950 | Usual Fee1: $285.00 | With Plan2: $93 | You Save: $192 | Saving Percentage: 67% |
Labial veneer (resin laminate) - direct | ADA Code: D2960 | Usual Fee1: $650.00 | With Plan2: $221 | You Save: $429 | Saving Percentage: 66% |
Labial veneer (porcelain laminate) - indirect | ADA Code: D2962 | Usual Fee1: $1345.00 | With Plan2: $355 | You Save: $990 | Saving Percentage: 74% |
Root canal treatment - front tooth | ADA Code: D3310 | Usual Fee1: $789.00 | With Plan2: $298 | You Save: $491 | Saving Percentage: 62% |
Root canal treatment - bicuspid | ADA Code: D3320 | Usual Fee1: $937.00 | With Plan2: $348 | You Save: $589 | Saving Percentage: 63% |
Root canal treatment - molar | ADA Code: D3330 | Usual Fee1: $1195.00 | With Plan2: $513 | You Save: $682 | Saving Percentage: 57% |
Bone replacement graft - retained natural tooth - first site in quadrant | ADA Code: D4263 | Usual Fee1: $353.00 | With Plan2: $202 | You Save: $151 | Saving Percentage: 43% |
Perio scaling and root planing (per quadrant) | ADA Code: D4341 | Usual Fee1: $277.00 | With Plan2: $95 | You Save: $182 | Saving Percentage: 66% |
Regular cleaning following periodontic procedure | ADA Code: D4910 | Usual Fee1: $150.00 | With Plan2: $72 | You Save: $78 | Saving Percentage: 52% |
Full upper denture | ADA Code: D5110 | Usual Fee1: $1532.00 | With Plan2: $675 | You Save: $857 | Saving Percentage: 56% |
Full lower denture | ADA Code: D5120 | Usual Fee1: $1500.00 | With Plan2: $675 | You Save: $825 | Saving Percentage: 55% |
Add clasp to existing partial denture | ADA Code: D5660 | Usual Fee1: $261.00 | With Plan2: $96 | You Save: $165 | Saving Percentage: 63% |
Surgical placement of implant body: endosteal implant | ADA Code: D6010 | Usual Fee1: $2150.00 | With Plan2: $1,768 | You Save: $382 | Saving Percentage: 18% |
Abutment supported cast metal crown (predominantly base metal) | ADA Code: D6063 | Usual Fee1: $1259.00 | With Plan2: $555 | You Save: $704 | Saving Percentage: 56% |
Implant supported crown high noble alloys | ADA Code: D6067 | Usual Fee1: $1418.00 | With Plan2: $725 | You Save: $693 | Saving Percentage: 49% |
Tooth replacement part of permanent bridge | ADA Code: D6210 | Usual Fee1: $1098.00 | With Plan2: $530 | You Save: $568 | Saving Percentage: 52% |
Single tooth removal - simple extraction | ADA Code: D7140 | Usual Fee1: $174.00 | With Plan2: $53 | You Save: $121 | Saving Percentage: 70% |
Extraction - impacted wisdom tooth (soft tissue) | ADA Code: D7220 | Usual Fee1: $330.00 | With Plan2: $131 | You Save: $199 | Saving Percentage: 60% |
Extraction - impacted wisdom tooth (partial bony) | ADA Code: D7230 | Usual Fee1: $415.00 | With Plan2: $176 | You Save: $239 | Saving Percentage: 58% |
Comprehensive orthodontic treatment of the transitional dentition | ADA Code: D8070 | Usual Fee1: $5562.00 | With Plan2: 20% Off | You Save: $1112.40* | Saving Percentage: 20% |
Full orthodontic child treatment (braces) | ADA Code: D8080 | Usual Fee1: $5658.00 | With Plan2: 20% Off | You Save: $1131.60* | Saving Percentage: 20% |
Full orthodontic adult treatment (braces) | ADA Code: D8090 | Usual Fee1: $5936.00 | With Plan2: 20% Off | You Save: $1187.20* | Saving Percentage: 20% |
External bleaching – per arch – performed in office | ADA Code: D9972 | Usual Fee1: $225.00 | With Plan2: 20% Off | You Save: $45.00* | Saving Percentage: 20% |
External bleaching - per tooth | ADA Code: D9973 | Usual Fee1: $185.00 | With Plan2: $135 | You Save: $50 | Saving Percentage: 27% |
Internal bleaching - per tooth | ADA Code: D9974 | Usual Fee1: $286.00 | With Plan2: 20% Off | You Save: $57.20* | Saving Percentage: 20% |
1 The [“Usual Fee”] is determined by DentalPlans.com, Inc., using benchmark data from FAIR Health, Inc. FAIR Health data is used under license. Fees may reflect combined fees from several different procedures into one procedure and may not be directly comparable to a specific benchmark in FAIR Health Data. Actual fees charged by your provider may vary for a variety of reasons.
2 Discounted fees are listed for visits to a participating general dentist. Any procedure not listed on the complete fee schedule will be discounted 20% off the provider's normal fee. Members will be charged the provider's Preferred Network Access by CIGNA contracted fees. Charges may vary from the sample fee schedule above. Consult with your provider prior to beginning any treatment.
This plan is based geographically by ZIP code in terms of provider participation and location. Fee schedules and savings may vary by ZIP code and by Provider within a ZIP code.
* Savings will be 20% off usual customary rate.