|
Zip Code 11234 |
ADA
Code |
Procedure |
**Usual
Fee |
Member
(Reduced)
Fee |
Savings
% |
|
0120 |
Periodic
oral evaluation |
$43 |
$24 |
44% |
|
0150 |
Comprehensive oral evaluation |
$73 |
$36 |
50% |
|
0210 |
Intraoral-complete
series (including bitewings) |
$123 |
$70 |
43% |
|
0330 |
Panoramic
film |
$106 |
$55 |
48% |
|
1110 |
Prophylaxis-adult |
$84 |
$54 |
35% |
|
1120 |
Prophylaxis-child |
$61 |
$38 |
37% |
|
2140 |
Amalgam-one surface, permanent |
$114 |
$54 |
52% |
|
2150 |
Amalgam-two surfaces, permanent |
$143 |
$71 |
50% |
|
2160 |
Amalgam-three surfaces, permanent |
$175 |
$87 |
50% |
|
2330 |
Resin-based composite-one surface, anterior |
$137 |
$71 |
48% |
|
2331 |
Resin-based composite-two surfaces, anterior |
$173 |
$94 |
45% |
|
2332 |
Resin-based composite-three surfaces, anterior |
$212 |
$125 |
41% |
|
2750 |
Crown-porcelain fused to high noble metal |
$1048 |
$535 |
48% |
|
2952 |
Cast post
and core in addition to crown |
$402 |
$184 |
54% |
|
3330 |
Root canal
therapy, molar (excluding final restoration) |
$947 |
$576 |
39% |
|
4341 |
Periodontal scaling and root planing, per quadrant |
$240 |
$117 |
51% |
|
4910 |
Periodontal maintenance procedures (following active therapy) |
$130 |
$89 |
31% |
|
5110 |
Complete
denture-maxillary |
$1421 |
$701 |
50% |
|
7110 |
Single
tooth |
$135 |
$65 |
51% |
|
7210 |
Surgical
removal of erupted tooth |
$256 |
$132 |
48% |
|
*** |
Comprehensive orthodontia treament sample. This is for a
24-month program based on CIGNA fees for ADA codes 8010, 8020
and 8030 |
$5563 |
$3143 |
43% |
