Procedure Type
Member Copay
Porcelain Crown
$225
Porcelain Inlay / Onlay
$185
Denture (Bridge)
$150
Oral Exam and Cleaning
$0
Root Canal (Anterior)
$80
Periodontal Maintenance
$30
Abutment
$485
X-Ray
$0
Resin Filling
$0
Extraction of Erupted Tooth
$5
Scaling and Root Planing
$40
Post & Core
$50
Denture Repair
$30
Anesthesia
$0
Post & Core
$50
Gingivectomy
$130
Bone Graft
$205
Tissue Graft
$125
Removal of Lesion or Cyst and Biopsy
$0
Desensitizing Medication
$15
Note: Procedure Type has been modified into “plain English” and multiple procedures grouped under a single procedure type. Your specific procedure may have a different code than the one listed above.
PLAN 1 (Previously Cigna $0 Copay)
PLAN 2 (Grandfathered SDCERA Cigna “Low” Option)