Dental Procedure Usual Fee* Discounted Fee for Plan Members** Sample Savings  Routine 6 Month (Check Up) $35 $24 $11  In Depth Check-Up $60 $36 $24  Bitewings - Four Films $45 $31 $14  Adult Cleaning $65 $54 $11  Child Cleaning $50 $38 $12  Sealant - Per Tooth $40 $30 $10  White Filling $110 $71 $39  Crown - Porcelain $950 $535 $415  Root Canal - Molar $785 $576 $209  Perio Scaling and Root Planing (Per Quadrant) $188 $117 $71  Upper Denture (Complete) $1,250 $701 $549  Tooth Replacement / Bridge Prosthetic $795 $504 $291  Single Tooth Extraction $110 $65 $45 The sample table above is a small selection of common procedures included in the CIGNA Dental Network AccessSM network. Most procedures covered under the negotiated fee schedule offer savings similar to the sample above. *Sources: American Dental Association (ADA) 2001 Regional Survey of Dental Fees. Fees may vary by region. **Actual savings will vary based on procedure, geographic location and the dentist's CIGNA Dental Network AccessSM discount. Consult with your provider prior to beginning treatment. Lab fees are additional. This plan is based geographically by ZIP codes in terms of provider participation and location. Fee schedules and savings may vary by ZIP code, and provider within a ZIP code.