CIGNAPlus Sample Savings Chart

Procedure	Usual Fee	Atlanta PPO Fee	Chicago PPO Fee	Dallas PPO Fee	Denver PPO Fee	Kansas City PPO Fee	New York City PPO Fee	Phoenix PPO Fee	Providence PPO Fee	San Francisco PPO Fee
Periodic Oral Evaluation	$57	$21	$21	$21	$25	$20	$25	$24	$23	$27
Comprehensive Oral Evaluation	$96	$32	$31	$31	$37	$29	$37	$36	$36	$41
Intraoral - Complete Series (inc. Bitewings)	$141	$66	$60	$60	$73	$57	$73	$70	$74	$81
Bitewings - 4 Films	$69	$26	$27	$27	$32	$25	$32	$31	$29	$36
Panoramic Film	$119	$54	$47	$47	$57	$44	$57	$55	$60	$63
Prophylaxis - Adult Teeth Cleaning	$101	$40	$47	$47	$56	$44	$56	$54	$44	$62
Prophylaxis - Child Teeth Cleaning	$74	$29	$32	$32	$40	$30	$40	$38	$33	$44
Sealant - Per Tooth	$60	$25	$27	$27	$31	$25	$31	$30	$27	$35
Resin, One Surface, Anterior	$173	$73	$61	$61	$74	$58	$74	$71	$81	$82
Crown - Porcelain Fused to High Noble Metal	$1,202	$601	$579	$546	$631	$515	$556	$594	$670	$680
Crown - Porcelain Fused to Noble Metal	$1,141	$583	$531	$501	$580	$473	$511	$545	$650	$626
Core Buildup, Including Any Pins	$292	$116	$96	$91	$106	$86	$93	$99	$130	$103
Anterior (Excluding Final Restoration) Root Canal	$810	$364	$316	$316	$381	$298	$381	$366	$405	$420
Bicuspid (Excluding Final Restoration) Root Canal	$946	$428	$369	$369	$444	$348	$444	$427	$477	$489
Molar (Excluding Final Restoration) Root Canal	$1,146	$524	$498	$498	$599	$470	$599	$576	$583	$720
Periodontal Scaling and Root Planing, Per Quadrant	$266	$123	$101	$101	$122	$95	$122	$117	$137	$134
Complete Denture - Maxillary	$1,816	$786	$759	$716	$827	$675	$729	$778	$875	$803