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Sample Fees and Savings 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%

* Fees Vary by Zip Codes
** Usual and Customary data is derived from the data supplied by NDAS © 2002 50th Percentile. The 50th percentile means that half of the providers will charge more and half will charge less than the values shown.
*** CIGNA does not offer a comprehensive ortho fee. This number is derived from the numbers shown for a typical 24-month treatment.

* This is not Insurance

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Disclaimer: Please note that this is not health insurance and we do not make payments directly to medical services providers. It is a discount program, and you are obligated to pay for all health care services. You will receive discounts for medical services at certain health care providers who have contracted with the plan. This plan is administered by AccessOne Consumer Health, Inc., 84 Villa Rd., Greenville, S.C.  29615 .

The program and its administrators have no liability for providing or guaranteeing service or the quality of service rendered.

If the Participant or the provider has a complaint regarding the program then he or she may go to www.accessonedmpo.com or call 800-896-1962 or write to Access One Consumer Health Inc. at the above address. This complaint will be addressed and the Participant will receive a response within 15 days of receipt of the complaint by the DMPO.

Note to Utah residents: this contract is not protected by the Utah Life and Health Guaranty Association