Cigna Dental Care DHMO) Patient Charge Schedule€¦ · Not all Network Dentists perform all listed services and it is suggested to check with your Network Dentist in advance of receiving

P7XV0

830591 10/11 P7XV092159

This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.

Important Highlights

Cigna Dental Care® (*DHMO)Patient Charge Schedule

• ThisPatientChargeScheduleappliesonlywhencovereddentalservicesareperformedbyyourNetworkDentist,unlessotherwiseauthorizedbyCignaDentalasdescribedinyourplandocuments.NotallNetworkDentistsperformalllistedservicesanditissuggestedtocheckwithyourNetworkDentistinadvanceofreceiving services.

• ThisPatientChargeScheduleappliestoSpecialtyCarewhenanappropriatereferralismadetoaNetworkSpecialtyPeriodontist,OrthodontistorOralSurgeon.YoumustverifywiththeNetworkSpecialtyDentistthatyourtreatmentplanhasbeenauthorizedforpaymentbyCignaDental.PriorauthorizationisnotrequiredforspecialtyreferralsforPediatricandEndodonticservices.YoumayselectaNetworkPediatricDentistforyourchildundertheageof7bycallingCustomerServiceat1.800.Cigna24togetalistofNetworkPediatricDentistsinyourarea.CoveragefortreatmentbyaPediatricDentistendsonyourchild’s7thbirthday;however,exceptionsformedicalreasonsmaybeconsideredonanindividualbasis.YourNetworkGeneralDentistwillprovidecareuponyourchild’s7thbirthday.

• Procedures NOT listed on this Patient Charge Schedule are NOT covered and are the patient’s responsibility at the dentist’s usual fees.

• TheadministrationofIVsedation,generalanesthesia,and/orNitrousOxideisnotcoveredexceptasspecificallylistedonthisPatientChargeSchedule.Theapplicationoflocalanestheticiscoveredaspartofyourdentaltreatment.

• CignaDentalconsidersinfectioncontroland/orsterilizationtobeincidentaltoandpartofthechargesforservicesprovidedandnotseparatelychargeable.

• ThisPatientChargeScheduleissubjecttoannualchangeinaccordancewiththeterms of the group agreement.

• ProcedureslistedonthePatientChargeSchedulearesubjecttotheplanlimitationsandexclusionsdescribedinyourplanbook/certificateofcoverageand/orgroupcontract.

Cigna Dental Care®Patient Charge Schedule (P7XV0)

-2-

Code Procedure Description Patient Charge

Office Visit Fee(Perpatient,perofficevisitinadditiontoanyotherapplicablepatient charges)

OfficeVisitFee $5.00

Diagnostic/Preventive –Oralevaluationsarelimitedtoacombinedtotalof4ofthefollowingevaluationsduringa12consecutivemonthperiod:PeriodicOralEvaluations(D0120),ComprehensiveOralEvaluations(D0150),ComprehensivePeriodontalEvaluations(D0180),andOralEvaluationsforPatientsUnder3YearsofAge(D0145).

D9310 Consultation(DiagnosticServiceProvidedbyDentistorPhysicianOtherthanRequestingDentistorPhysician)

$12.00

D9430 OfficeVisitforObservation–NoOtherServicesPerformed $6.00

D9450 CasePresentation–DetailedandExtensiveTreatmentPlanning

$0.00

D0120 PeriodicOralEvaluation–EstablishedPatient $0.00

D0140 LimitedOralEvaluation–ProblemFocused $0.00

D0145 OralEvaluationforaPatientUnder3YearsofAgeandCounselingwithPrimaryCaregiver

$0.00

D0150 ComprehensiveOralEvaluation–NeworEstablishedPatient $0.00

D0160 DetailedandExtensiveOralEvaluation–ProblemFocused, ByReport

$0.00

D0170 Re-evaluation–Limited,ProblemFocused(NotPostoperativeVisit)

$0.00

D0210 X-RaysIntraoral–CompleteSeries(IncludingBitewings)(Limit 1 Every 3 Years)

$0.00

D0220 X-RaysIntraoral–Periapical–FirstFilm $0.00

D0230 X-RaysIntraoral–Periapical–EachAdditionalFilm $0.00

n AllpatientchargesmustcorrespondtothePatientChargeScheduleineffectonthedate the procedure is initiated.

n TheAmericanDentalAssociationmayperiodicallychangeCDTCodesordefinitions.Differentcodesmaybeusedtodescribethesecoveredprocedures.

Important Highlights (continued)


-3-


D0240 X-RaysIntraoral–OcclusalFilm $0.00

D0250 X-RaysExtraoral–FirstFilm $0.00

D0260 X-RaysExtraoral–EachAdditionalFilm $0.00

D0270 X-Rays(Bitewing)–SingleFilm $0.00

D0272 X-Rays(Bitewings)–2Films $0.00



D0277 X-Rays(Bitewings,Vertical)–7to8Films $0.00

D0330 X-Rays(PanoramicFilm)–(Limit 1 Every 3 Years) $0.00

D0350 Oral/FacialPhotographicImages $0.00

D0415 CollectionofMicroorganismsforCultureandSensitivity $0.00

D0425 CariesSusceptibilityTests $0.00

D0431 OralCancerScreeningUsingaSpecialLightSource $50.00

D0460 PulpVitalityTests $0.00

D0470 Diagnostic Casts $0.00

D0472 PathologyReport–GrossExaminationofLesion (OnlyWhenToothRelated)

$0.00

D0473 PathologyReport–MicroscopicExaminationofLesion (OnlyWhenToothRelated)

$0.00

D0474 PathologyReport–MicroscopicExaminationofLesionandArea(OnlyWhenToothRelated)

$0.00

D0486 AccessionofBrushBiopsySample,MicroscopicExamination,PreparationandTransmissionofWrittenReport

$0.00

D1110 Prophylaxis(Cleaning)–Adult(Limit 2 per Calendar Year) $0.00

AdditionalProphylaxis(Cleaning)–InAdditiontothe 2Prophylaxes(Cleanings)AllowedperCalendarYear

$55.00

D1120 Prophylaxis(Cleaning)–Child(Limit 2 per Calendar Year) $0.00

AdditionalProphylaxis(Cleaning)–InAdditiontothe 2Prophylaxes(Cleanings)AllowedperCalendarYear

$45.00

D1203 TopicalApplicationofFluoride–Child(Up to 19th Birthday) (Limited to 2 per Calendar Year). There is a Combined Limit of a Total of 2 D1203s and/or D1206s per Calendar Year.

$0.00


-4-


D1204 TopicalFluorideApplication–Adult $0.00

D1206 TopicalFluorideVarnish–TherapeuticApplicationforModeratetoHighCariesRiskPatients–Child(Up to 19th Birthday) (Limited to 2 per Calendar Year). There is a Combined Limit of a Total of 2 D1203s and/or D1206s per Calendar Year.

$0.00

D1310 NutritionalCounselingforControlofDentalDisease $0.00

D1320 TobaccoCounselingfortheControlandPreventionofOralDisease

$0.00

D1330 OralHygieneInstructions $0.00

D1351 Sealant – Per Tooth $12.00

D1352 PreventiveResinRestorationinaModeratetoHighCariesRiskPatient – Permanent Tooth

$12.00

D1510 SpaceMaintainer–Fixed–Unilateral $35.00

D1515 SpaceMaintainer–Fixed–Bilateral $35.00

D1520 SpaceMaintainer–Removable–Unilateral $45.00

D1525 SpaceMaintainer–Removable–Bilateral $45.00

D1550 RecementationofSpaceMaintainer $6.00

D1555 RemovalofFixedSpaceMaintainer $6.00

Restorative (Fillings)

D2140 Amalgam–1Surface,PrimaryorPermanent $0.00

D2150 Amalgam–2Surfaces,PrimaryorPermanent $0.00

D2160 Amalgam–3Surfaces,PrimaryorPermanent $0.00

D2161 Amalgam–4orMoreSurfaces,PrimaryorPermanent $0.00

D2330 Resin-BasedComposite–1Surface,Anterior $0.00

D2331 Resin-BasedComposite–2Surfaces,Anterior $0.00

D2332 Resin-BasedComposite–3Surfaces,Anterior $0.00

D2335 Resin-BasedComposite–4orMoreSurfacesorInvolvingIncisalAngle,Anterior

$0.00

D2390 Resin-BasedCompositeCrown,Anterior $45.00

D2391 Resin-BasedComposite–1Surface,Posterior $70.00


-5-


D2392 Resin-BasedComposite–2Surfaces,Posterior $80.00

D2393 Resin-BasedComposite–3Surfaces,Posterior $95.00

D2394 Resin-BasedComposite–4orMoreSurfaces,Posterior $105.00

Crown and Bridge – Allchargesforcrownandbridge(fixedpartialdenture)areperunit(eachreplacementorsupportingtoothequals1unit)–Replacementlimit1every5years.Thechargesbelowincludethecostofbasemetal.Noblemetalandhighnoblemetal(precious)ortitaniummetal,ifused,willbechargedtotheMemberat an additional maximum amount of $150.00 per tooth. If a cast post and core is made ofhighnoblemetal,anadditionalfeeupto$100.00pertoothmaybechargedfortheupgradedpostandcore.Porcelain,ifusedonmolarteeth,willbechargedtotheMemberatanadditionalmaximumamountof$75.00pertooth.Porcelain/Ceramicsubstratecrownsonmolarteetharenotcovered.

ComplexRehabilitation–ANADDITIONAL$125CHARGEPERUNITFORMULTIPLECROWNUNITS/COMPLEXREHABILITATION(6 or more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit – ask your dentist for the guidelines)

D2510 Inlay–Metallic–1Surface $260.00

D2520 Inlay–Metallic–2Surfaces $260.00

D2530 Inlay–Metallic–3orMoreSurfaces $260.00

D2542 Onlay–Metallic–2Surfaces $260.00

D2543 Onlay–Metallic–3Surfaces $260.00

D2544 Onlay–Metallic–4orMoreSurfaces $260.00

D2740 Crown–Porcelain/CeramicSubstrate $285.00

D2750 Crown–PorcelainFusedtoHighNobleMetal $270.00

D2751 Crown–PorcelainFusedtoPredominantlyBaseMetal $240.00

D2752 Crown–PorcelainFusedtoNobleMetal $270.00

D2780 Crown–3/4CastHighNobleMetal $260.00

D2781 Crown–3/4CastPredominantlyBaseMetal $225.00

D2782 Crown–3/4CastNobleMetal $260.00

D2783 Crown–3/4Porcelain/Ceramic $240.00

D2790 Crown–FullCastHighNobleMetal $260.00


-6-


D2791 Crown–FullCastPredominantlyBaseMetal $225.00

D2792 Crown–FullCastNobleMetal $260.00

D2794 Crown–Titanium $260.00

D2799 ProvisionalCrown $100.00

D2610 Inlay–Porcelain/Ceramic,1Surface $240.00

D2620 Inlay–Porcelain/Ceramic,2Surfaces $240.00

D2630 Inlay–Porcelain/Ceramic,3orMoreSurfaces $240.00

D2642 Onlay–Porcelain/Ceramic,2Surfaces $240.00


D2644 Onlay–Porcelain/Ceramic,4orMoreSurfaces $240.00

D2650 Inlay–Resin-BasedComposite,1Surface $225.00

D2651 Inlay–Resin-BasedComposite,2Surfaces $225.00

D2652 Inlay–Resin-BasedComposite,3orMoreSurfaces $225.00

D2662 Onlay–Resin-BasedComposite,2Surfaces $225.00

D2663 Onlay–Resin-BasedComposite,3Surfaces $225.00

D2664 Onlay–Resin-BasedComposite,4orMoreSurfaces $225.00

D2710 Crown–Resin-BasedComposite,Indirect $225.00

D2712 Crown–3/4Resin-BasedComposite,Indirect $225.00

D2720 Crown–ResinwithHighNobleMetal $260.00

D2721 Crown–ResinwithPredominantlyBaseMetal $225.00

D2722 Crown–ResinwithNobleMetal $260.00

D2910 RecementInlay–OnlayorPartialCoverageRestoration $0.00

D2915 RecementCastorPrefabricatedPostandCore $0.00

D2920 RecementCrown $0.00

D2930 PrefabricatedStainlessSteelCrown–PrimaryTooth $35.00

D2931 PrefabricatedStainlessSteelCrown–PermanentTooth $35.00

D2932 PrefabricatedResinCrown $45.00

D2933 PrefabricatedStainlessSteelCrownwithResinWindow $45.00

D2934 PrefabricatedEstheticCoatedStainlessSteelCrown– PrimaryTooth

$130.00


-7-


D2940 ProtectiveRestoration $6.00

D2950 CoreBuildup–IncludingAnyPins $65.00

D2951 PinRetention–PerTooth–InAdditiontoRestoration $10.00

D2952 PostandCore–InAdditiontoCrown,IndirectlyFabricated $65.00

D2953 EachAdditionalIndirectlyPrefabricatedPost–SameTooth $65.00

D2954 PrefabricatedPostandCore–InAdditiontoCrown $40.00

D2957 EachAdditionalPrefabricatedPost–SameTooth $40.00

D2960 LabialVeneer(ResinLaminate)–Chairside $250.00

D2970 TemporaryCrown(FracturedTooth) $6.00

D2971 AdditionalProcedurestoConstructNewCrownUnderExistingPartialDentureFramework

$65.00

D2980 CrownRepair,ByReport $18.00

D6210 Pontic–CastHighNobleMetal $260.00

D6211 Pontic–CastPredominantlyBaseMetal $225.00

D6212 Pontic–CastNobleMetal $260.00

D6214 Pontic – Titanium $260.00

D6240 Pontic–PorcelainFusedtoHighNobleMetal $250.00

D6241 Pontic–PorcelainFusedtoPredominantlyBaseMetal $220.00

D6242 Pontic–PorcelainFusedtoNobleMetal $250.00

D6245 Pontic–Porcelain/Ceramic $220.00

D6250 Pontic–ResinwithHighNobleMetal $260.00

D6251 Pontic–ResinwithPredominantlyBaseMetal $225.00

D6252 Pontic–ResinwithNobleMetal $260.00

D6253 Provisional Pontic $225.00

D6545 Retainer–CastMetalforResinBondedFixedProsthesis $225.00

D6600 Inlay–Porcelain/Ceramic,2Surfaces $240.00

D6601 Inlay–Porcelain/Ceramic,3orMoreSurfaces $240.00

D6602 Inlay–CastHighNobleMetal,2Surfaces $260.00

D6603 Inlay–CastHighNobleMetal,3orMoreSurfaces $260.00

D6604 Inlay–CastPredominantlyBaseMetal,2Surfaces $225.00


-8-


D6605 Inlay–CastPredominantlyBaseMetal,3orMoreSurfaces $225.00

D6606 Inlay–CastNobleMetal,2Surfaces $260.00

D6607 Inlay–CastNobleMetal,3orMoreSurfaces $260.00


D6609 Onlay–Porcelain/Ceramic,3orMoreSurfaces $240.00

D6610 Onlay–CastHighNobleMetal,2Surfaces $260.00

D6611 Onlay–CastHighNobleMetal,3orMoreSurfaces $260.00

D6612 Onlay–CastPredominantlyBaseMetal,2Surfaces $225.00

D6613 Onlay–CastPredominantlyBaseMetal,3orMoreSurfaces $225.00

D6614 Onlay–CastNobleMetal,2Surfaces $260.00

D6615 Onlay–CastNobleMetal,3orMoreSurfaces $260.00

D6624 Inlay–Titanium $250.00

D6634 Onlay–Titanium $220.00

D6710 Crown–IndirectResinBasedComposite $225.00

D6720 Crown–ResinwithHighNobleMetal $260.00

D6721 Crown–ResinwithPredominantlyBaseMetal $225.00

D6722 Crown–ResinwithNobleMetal $260.00

D6740 Crown–Porcelain/Ceramic $220.00

D6750 Crown–PorcelainFusedtoHighNobleMetal $250.00

D6751 Crown–PorcelainFusedtoPredominantlyBaseMetal $220.00

D6752 Crown–PorcelainFusedtoNobleMetal $250.00

D6780 Crown–3/4CastHighNobleMetal $260.00

D6781 Crown–3/4CastPredominantlyBaseMetal $225.00

D6782 Crown–3/4CastNobleMetal $260.00

D6783 Crown–3/4Porcelain/Ceramic $220.00

D6790 Crown–FullCastHighNobleMetal $260.00

D6791 Crown–FullCastPredominantlyBaseMetal $225.00

D6792 Crown–FullCastNobleMetal $260.00

D6794 Crown–Titanium $260.00


-9-


D6930 RecementFixedPartialDenture $0.00

D6950 PrecisionAttachment $195.00

Implant Supported Prosthetics – Allchargesforcrownandbridge(fixedpartialdenture)areperunit(eachreplacementonasupportingimplant(s)equals1unit)–Replacementlimit1every5years.Allchargesforanimplantsupporteddenturearelimitedtoreplacementof1every5years.Thechargesbelowincludethecostofbasemetal.Noblemetal andhighnoblemetal(precious)ortitaniummetal,ifused,willbecharged to the Member at an additional maximum amount of $150.00 per tooth. If a castpostandcoreismadeofhighnoblemetal,anadditionalfeeupto$100.00pertoothmaybechargedfortheupgradedpostandcore.Porcelain,ifusedonmolarteeth,willbechargedtotheMemberatanadditionalmaximumamountof$75.00pertooth.Porcelain/Ceramicsubstratecrownsonmolarteetharenotcovered.

ComplexRehabilitationonImplantSupportedProstheticProcedures–ANADDITIONAL$125CHARGEPERUNIT FORMULTIPLECROWNUNITS/COMPLEXREHABILITATION (6 or more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit – ask your dentist for the guidelines)

D6053 Implant/AbutmentSupportedRemovableDentureforCompletelyEdentulousArch

$725.00

D6054 Implant/AbutmentSupportedRemovableDentureforPartiallyEdentulousArch

$740.00

D6058 AbutmentSupportedPorcelain/CeramicCrown $625.00

D6059 AbutmentSupportedPorcelainFusedtoMetalCrown(HighNobleMetal)

$760.00

D6060 AbutmentSupportedPorcelainFusedtoMetalCrown(PredominantlyBaseMetal)

$580.00

D6061 AbutmentSupportedPorcelainFusedtoMetalCrown(NobleMetal)

$760.00

D6062 AbutmentSupportedCastMetalCrown(HighNobleMetal) $710.00

D6063 AbutmentSupportedCastMetalCrown(PredominantlyBaseMetal)

$525.00

D6064 AbutmentSupportedCastMetalCrown(NobleMetal) $710.00

D6065 ImplantSupportedPorcelain/CeramicCrown $625.00


-10-


D6066 ImplantSupportedPorcelainFusedtoMetalCrown(Titanium,TitaniumAlloy,HighNobleMetal)

$760.00

D6067 ImplantSupportedMetalCrown(Titanium,TitaniumAlloy,HighNobleMetal)

$710.00

D6068 AbutmentSupportedRetainerforPorcelain/CeramicFixedPartial Denture

$560.00

D6069 AbutmentSupportedRetainerforPorcelainFusedtoMetalFixedPartialDenture(HighNobleMetal)

$740.00

D6070 AbutmentSupportedRetainerforPorcelainFusedtoMetalFixedPartialDenture(PredominantlyBaseMetal)

$560.00

D6071 AbutmentSupportedRetainerforPorcelainFusedtoMetalFixedPartialDenture(NobleMetal)

$740.00

D6072 AbutmentSupportedRetainerforCastMetalFixedPartialDenture(HighNobleMetal)

$710.00

D6073 AbutmentSupportedRetainerforCastMetalFixedPartialDenture(PredominantlyBaseMetal)

$525.00

D6074 AbutmentSupportedRetainerforCastMetalFixedPartialDenture(NobleMetal)

$710.00

D6075 ImplantSupportedRetainerforCeramicFixedPartialDenture $560.00

D6076 ImplantSupportedRetainerforPorcelainFusedtoMetalFixedPartialDenture(Titanium,TitaniumAlloy,HighNobleMetal)

$740.00

D6077 ImplantSupportedRetainerforCastMetalFixedPartialDenture(Titanium,TitaniumAlloy,HighNobleMetal)

$710.00

D6078 Implant/AbutmentSupportedFixedDentureforCompletelyEdentulousArch

$725.00

D6079 Implant/AbutmentSupportedFixedDentureforPartiallyEdentulousArch

$740.00

D6092 RecementImplant/AbutmentSupportedCrown $40.00

D6093 RecementImplant/AbutmentSupportedFixedPartialDenture

$40.00

D6094 AbutmentSupportedCrown(Titanium) $710.00

D6194 AbutmentSupportedRetainerCrownforFixedPartialDenture (Titanium)

$710.00


-11-


Endodontics (RootCanalTreatment,ExcludingFinalRestorations)

D3110 PulpCap–Direct(ExcludingFinalRestoration) $0.00

D3120 PulpCap–Indirect(ExcludingFinalRestoration) $0.00

D3220 Pulpotomy–RemovalofPulp,NotPartofaRootCanal $12.00

D3221 PulpalDebridement(Nottobeusedwhenrootcanalisdoneonthesameday)

$55.00

D3222 PartialPulpotomyforApexogenesis–PermanentToothwithIncompleteRootDevelopment

$17.00

D3230 PulpalTherapy(ResorbableFilling)–Anterior,PrimaryTooth(ExcludingFinalRestoration)

$40.00

D3240 PulpalTherapy(ResorbableFilling)–Posterior,PrimaryTooth(ExcludingFinalRestoration)

$45.00

D3310 AnteriorRootCanal–PermanentTooth(ExcludingFinalRestoration)

$100.00

D3320 BicuspidRootCanal–PermanentTooth(ExcludingFinalRestoration)

$150.00

D3330 MolarRootCanal–PermanentTooth(ExcludingFinalRestoration)

$305.00

D3331 TreatmentofRootCanalObstruction–NonsurgicalAccess $105.00

D3332 IncompleteEndodonticTherapy–Inoperable,UnrestorableorFracturedTooth

$85.00

D3333 InternalRootRepairofPerforationDefects $105.00

D3346 RetreatmentofPreviousRootCanalTherapy–Anterior $165.00

D3347 RetreatmentofPreviousRootCanalTherapy–Bicuspid $215.00

D3348 RetreatmentofPreviousRootCanalTherapy–Molar $340.00

D3351 Apexification/Recalcification–InitialVisit(ApicalClosure/CalcificRepairofPerforations,RootResorption,etc.)

$95.00

D3352 Apexification/Recalcification–InterimMedicationReplacement(ApicalClosure/CalcificRepairofPerforations,RootResorption,etc.)

$80.00

D3353 Apexification/Recalcification–FinalVisit(IncludesCompletedRootCanalTherapy–ApicalClosure/CalcificRepairofPerforations,RootResorption,etc.)

$80.00


-12-


D3410 Apicoectomy/PeriradicularSurgery–Anterior $115.00

D3421 Apicoectomy/PeriradicularSurgery–Bicuspid(FirstRoot) $115.00

D3425 Apicoectomy/PeriradicularSurgery–Molar(FirstRoot) $115.00

D3426 Apicoectomy/PeriradicularSurgery(EachAdditionalRoot) $75.00

D3430 RetrogradeFillingperRoot $75.00

D3450 RootAmputation–PerRoot $115.00

D3920 Hemisection(IncludingAnyRootRemoval),NotIncludingRootCanalTherapy

$110.00

Periodontics(TreatmentofSupportingTissues[GumandBone]oftheTeeth) Periodontal regenerative procedures are limited to 1 regenerative procedure per site(orpertooth,ifapplicable),whencoveredonthePatientChargeSchedule.TheRelevantProcedureCodesareD4263,D4264,D4266andD4267.Localizeddeliveryofantimicrobialagentsislimitedto8teeth(or8sites,ifapplicable)per12consecutivemonths,whencoveredonthePatientChargeSchedule.

D0180 ComprehensivePeriodontalEvaluation–NeworEstablishedPatient

$0.00

D4210 GingivectomyorGingivoplasty–4orMoreTeethperQuadrant $160.00

D4211 GingivectomyorGingivoplasty–1to3TeethperQuadrant $100.00

D4240 GingivalFlap(IncludingRootPlaning)–4orMoreTeeth perQuadrant

$185.00

D4241 GingivalFlap(IncludingRootPlaning)–1to3Teeth perQuadrant

$140.00

D4245 ApicallyPositionedFlap $200.00

D4249 ClinicalCrownLengthening–HardTissue $155.00

D4260 OsseousSurgery–4orMoreTeethperQuadrant $360.00

D4261 OsseousSurgery–1to3TeethperQuadrant $275.00

D4263 BoneReplacementGraft–FirstSiteinQuadrant $250.00

D4264 BoneReplacementGraft–EachAdditionalSiteinQuadrant $115.00

D4265 BiologicMaterialstoAidinSoftandOsseousTissueRegeneration

$95.00

D4266 GuidedTissueRegeneration–ResorbableBarrierperSite $215.00

D4267 GuidedTissueRegeneration–NonresorbableBarrierperSite(IncludesMembraneRemoval)

$255.00


-13-


D4270 PedicleSoftTissueGraftProcedure $300.00

D4271 FreeSoftTissueGraftProcedure(IncludingDonorSiteSurgery)

$300.00

D4273 SubepithelialConnectiveTissueGraftProcedures,PerTooth $75.00

D4274 DistalorProximalWedgeProcedure(WhenNotPerformedinConjunctionwithSurgicalProceduresintheSameAnatomicalArea)

$85.00

D4275 SoftTissueAllograft $460.00

D4341 PeriodontalScalingandRootPlaning–4orMoreTeethperQuadrant(Limit 4 Quadrants per Consecutive 12 Months)

$50.00

D4342 PeriodontalScalingandRootPlaning–1to3Teeth–perQuadrant(Limit 4 Quadrants per Consecutive 12 Months)

$40.00

D4355 FullMouthDebridementtoAllowEvaluationandDiagnosis (1 per Lifetime)

$50.00

D4381 LocalizedDeliveryofAntimicrobialAgentsperTooth–ByReport

$60.00

D4910 Periodontal Maintenance (Limited to 2 per Calendar Year) (Only Covered after Active Therapy)

$40.00

AdditionalPeriodontalMaintenanceProcedures(Beyond2perCalendarYear)

$70.00

Periodontal Charting for Planning Treatment of Periodontal Disease

$0.00

PeriodontalHygieneInstruction $0.00

D9940 OcclusalGuard–ByReport(Limit 1 per 24 Months) $125.00

D9942 Repairand/orRelineofOcclusalGuard $40.00

D9951 OcclusalAdjustmentLimited $45.00

D9952 OcclusalAdjustmentComplete $70.00

Prosthetics(RemovableToothReplacement–Dentures)Includesupto4adjustmentswithinfirst6monthsafterinsertion–Replacementlimit1every5years.CharacterizationisconsideredanupgradewithmaximumadditionalchargetotheMember of $200.00 per denture.

D5110 FullUpperDenture $225.00

D5120 FullLowerDenture $225.00


-14-


D5130 ImmediateFullUpperDenture $245.00

D5140 ImmediateFullLowerDenture $245.00

D5211 UpperPartialDenture–ResinBase(IncludingClasps, RestsandTeeth)

$225.00

D5212 LowerPartialDenture–ResinBase(IncludingClasps, RestsandTeeth)

$225.00

D5213 UpperPartialDenture–CastMetalFamework(IncludingClasps,RestsandTeeth)

$240.00

D5214 LowerPartialDenture–CastMetalFramework(IncludingClasps,RestsandTeeth)

$240.00

D5225 UpperPartialDenture–FlexibleBase(IncludingClasps, RestsandTeeth)

$165.00

D5226 LowerPartialDenture–FlexibleBase(IncludingClasps, RestsandTeeth)

$165.00

D5281 RemovableUnilateralPartialDenture–OnePieceCastMetalIncluding Clasps and Teeth)

$225.00

D5410 AdjustCompleteDenture–Upper $12.00

D5411 AdjustCompleteDenture–Lower $12.00

D5421 AdjustPartialDenture–Upper $12.00

D5422 AdjustPartialDenture–Lower $12.00

D5850 TissueConditioning–Upper $12.00

D5851 TissueConditioning–Lower $12.00

D5862 PrecisionAttachment–ByReport $160.00

Repairs to Prosthetics

D5510 RepairBrokenCompleteDentureBase $40.00

D5520 ReplaceMissingorBrokenTeeth–CompleteDenture (EachTooth)

$40.00

D5610 RepairResinDentureBase $40.00

D5620 RepairCastFramework $40.00

D5630 RepairorReplaceBrokenClasp $45.00

D5640 ReplaceBrokenTeeth–PerTooth $40.00

D5650 AddToothtoExistingPartialDenture $40.00


-15-


D5660 AddClasptoExistingPartialDenture $45.00

D5670 ReplaceAllTeethandAcryliconCastMetalFramework–Upper

$200.00

D5671 ReplaceAllTeethandAcryliconCastMetalFramework–Lower

$200.00

Denture Relining(Limit1Every36Months)

D5710 RebaseCompleteUpperDenture $75.00

D5711 RebaseCompleteLowerDenture $75.00

D5720 RebaseUpperPartialDenture $75.00

D5721 RebaseLowerPartialDenture $75.00

D5730 RelineCompleteUpperDenture–Chairside $45.00

D5731 RelineCompleteLowerDenture–Chairside $45.00

D5740 RelineUpperPartialDenture–Chairside $45.00

D5741 RelineLowerPartialDenture–Chairside $45.00

D5750 RelineCompleteUpperDenture–Laboratory $75.00

D5751 RelineCompleteLowerDenture–Laboratory $75.00

D5760 RelineUpperPartialDenture–Laboratory $75.00

D5761 RelineLowerPartialDenture–Laboratory $75.00

Interim Dentures(Limit1Every5Years)

D5810 InterimCompleteDenture–Upper $280.00

D5811 InterimCompleteDenture–Lower $280.00

D5820 InterimPartialDenture–Upper $95.00

D5821 InterimPartialDenture–Lower $95.00

Oral Surgery (IncludesRoutinePostoperativeTreatment)SurgicalRemovalofImpactedTooth–Notcoveredforagesbelow15unlesspathology(disease) exists.

D7111 ExtractionofCoronalRemnants–DeciduousTooth $6.00

D7140 Extraction,EruptedToothorExposedRoot–Elevation and/orForcepsRemoval

$6.00


-16-


D7210 SurgicalRemovalofEruptedTooth–RemovalofBone and/orSectionofTooth

$40.00

D7220 RemovalofImpactedTooth–SoftTissue $65.00

D7230 RemovalofImpactedTooth–PartiallyBony $85.00

D7240 RemovalofImpactedTooth–CompletelyBony $110.00

D7241 RemovalofImpactedTooth–CompletelyBony,UnusualComplications(NarrativeRequired)

$135.00

D7250 SurgicalRemovalofResidualToothRoots–CuttingProcedure $50.00

D7251 Coronectomy-IntentionalPartialToothRemoval $85.00

D7260 OroantralFistulaClosure $135.00

D7261 PrimaryClosureofaSinusPerforation $135.00

D7270 ToothStabilizationofAccidentallyEvulsedorDisplacedTooth $105.00

D7280 SurgicalAccessofanUneruptedTooth(Excluding Wisdom Teeth)

$110.00

D7283 PlacementofDevicetoFacilitateEruptionofImpactedTooth $110.00

D7285 BiopsyofOralTissue–Hard(Bone,Tooth)(Tooth Related – Not allowed when in conjunction with another surgical procedure)

$0.00

D7286 BiopsyofOralTissue–Soft(AllOthers)(Tooth Related – Not allowed when in conjunction with another surgical procedure)

$0.00

D7287 ExfoliativeCytologicalSampleCollection $50.00

D7288 BrushBiopsy–TransepithelialSampleCollection $50.00

D7310 AlveoloplastyinConjunctionwithExtractions– 4orMoreTeethorToothSpacesperQuadrant

$65.00

D7311 AlveoloplastyinConjunctionwithExtractions– 1to3TeethorToothSpacesperQuadrant

$65.00

D7320 AlveoloplastyNotinConjunctionwithExtractions– 4orMoreTeethorToothSpacesperQuadrant

$85.00

D7321 AlveoloplastyNotinConjunctionwithExtractions– 1to3TeethorToothSpacesperQuadrant

$85.00

D7450 RemovalofBenignOdontogenicCystorTumor– Upto1.25cm

$0.00

D7451 RemovalofBenignOdontogenicCystorTumor– Greaterthan1.25cm

$0.00


-17-


D7471 RemovalofLateralExostosis–MaxillaorMandible $100.00

D7472 RemovalofTorusPalatinus $75.00

D7473 RemovalofTorusMandibularis $75.00

D7485 SurgicalReductionofOsseousTuberosity $60.00

D7510 IncisionandDrainageofAbscess–IntraoralSoftTissue $40.00

D7511 IncisionandDrainageofAbscess–IntraoralSoftTissueComplicated

$40.00

D7520 IncisionandDrainageofAbscess–ExtraoralSoftTissue $40.00

D7521 IncisionandDrainageofAbscess–ExtraoralSoftTissue–Complicated(IncludesDrainageofMultipleFascialSpaces)

$40.00

D7910 SutureofRecentSmallWoundsupto5cm $35.00

D7960 Frenulectomy–AlsoKnownasFrenectomyorFrenotomy–SeparateProcedureNotIncidentaltoAnother

$50.00

D7963 Frenuloplasty $50.00

Orthodontics (ToothMovement)OrthodonticTreatment(Maximumbenefitof24monthsofinterceptiveand/orcomprehensivetreatment.Atypicalcasesorcasesbeyond24monthsrequireanadditionalpaymentbythepatient.)

D8050 InterceptiveOrthodonticTreatmentofthePrimary Dentition – Banding

$485.00

D8060 InterceptiveOrthodonticTreatmentoftheTransitionalDentition – Banding

$485.00

D8070 ComprehensiveOrthodonticTreatmentoftheTransitionalDentition – Banding

$485.00

D8080 ComprehensiveOrthodonticTreatmentoftheAdolescentDentition – Banding

$485.00

D8090 ComprehensiveOrthodonticTreatmentoftheAdult Dentition – Banding

$485.00

D8210 RemovableApplianceTherapy $0.00

D8220 FixedApplianceTherapy $0.00

D8660 Pre-OrthodonticTreatmentVisit $125.00


-18-


D8670 PeriodicOrthodonticTreatmentVisit–AsPartofContract

Children–Upto19thBirthday:

24-MonthTreatmentFee $1,600.00

Charge per Month for 24 Months $67.00

Adults:

24-MonthTreatmentFee $2,600.00

Charge per Month for 24 Months $108.00

D8680 OrthodonticRetention–RemovalofAppliances,ConstructionandPlacementofRetainer(s)

$295.00

D8693 RebondingorRecementing;and/orRepair,AsRequired,ofFixedRetainers

$0.00

D8999 UnspecifiedOrthodonticProcedure–ByReport(Orthodontic Treatment Plan and Records)

$290.00

General Anesthesia/IV Sedation –GeneralanesthesiaiscoveredwhenperformedbyanOralSurgeonwhenmedicallynecessaryforcoveredprocedureslistedonthePatientChargeSchedule.IVsedationiscoveredwhenperformedbyaPeriodontistorOralSurgeonwhenmedicallynecessaryforcoveredprocedureslistedonthePatientCharge Schedule. Plan limitation for this benefit is 1 hour per appointment. There is nocoverageforgeneralanesthesiaorintravenoussedationwhenusedforthepurposeofanxietycontrolorpatientmanagement.

D9211 RegionalBlockAnesthesia $0.00

D9212 TrigeminalDivisionBlockAnesthesia $0.00

D9215 LocalAnesthesia $0.00

D9220 GeneralAnesthesia–First30Minutes $160.00

D9221 GeneralAnesthesia–EachAdditional15Minutes $75.00

D9241 IVConsciousSedation–First30Minutes $160.00

D9242 IVConsciousSedation–EachAdditional15Minutes $75.00

D9610 TherapeuticParenteralDrug,SingleAdministration $15.00

D9612 TherapeuticParenteralDrugs,2orMoreAdministrations,Different Medications

$25.00

D9630 OtherDrugsand/orMedicaments–ByReport $15.00

D9910 ApplicationofDesensitizingMedicament $15.00


-19-


Emergency Services

D9110 Palliative(Emergency)TreatmentofDentalPain–MinorProcedure

$6.00

D9120 FixedPartialDentureSectioning $0.00

D9440 OfficeVisit–AfterRegularlyScheduledHours $40.00

Miscellaneous Services–ExternalBleaching(D9972)islimitedtotheuseoftake-homebleachingtrays.Allotherbleachingmethodsarenotcovered.

D9972 ExternalBleachingperArch $125.00

ThismaycontainCDTcodesand/orportionsof,orexcerptsfromtheNomenclaturecontainedwithintheCurrent Dental Terminology,acopyrightedpublicationprovidedbytheAmericanDentalAssociation.TheAmericanDentalAssociationdoesnotendorseanycodeswhicharenotincludedinitscurrentpublication.

* The term “DHMO” is used to refer to product designs that may differ by state of residence of enrollee, including but not limited to, prepaid plans, managed care plans, and plans with open access features.

“Cigna” and “Cigna Dental” are registered service marks and the “Tree of Life” logo is a service mark of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries, including Connecticut General Life Insurance Company (“CGLIC”), Cigna Health and Life Insurance Company (“CHLIC”), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. (“CDHI”) and its subsidiaries, and not by Cigna Corporation. The Cigna Dental Care plan is provided by Cigna Dental Health Plan of Arizona, Inc.; Cigna Dental Health of California, Inc.; Cigna Dental Health of Colorado, Inc.; Cigna Dental Health of Delaware, Inc.; Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes; Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska); Cigna Dental Health of Kentucky, Inc.; Cigna Dental Health of Maryland, Inc.; Cigna Dental Health of Missouri, Inc.; Cigna Dental Health of New Jersey, Inc.; Cigna Dental Health of North Carolina, Inc.; Cigna Dental Health of Ohio, Inc.; Cigna Dental Health of Pennsylvania, Inc.; Cigna Dental Health of Texas, Inc.; and Cigna Dental Health of Virginia, Inc. In other states, the Cigna Dental Care plan is underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc., and administered by CDHI.

830591 10/11 © 2011 Cigna

Afteryourenrollmentiseffective:CallthedentalofficeidentifiedinyourWelcomeKit.Ifyouwishtochangedentaloffices,atransfercanbearrangedatnochargebycallingCignaDentalatthetoll-freenumberlistedonyourIDcardorplanmaterials.Multiplewaystolocatea*DHMONetworkGeneralDentist:

• Onlineproviderdirectoryatwww.Cigna.com

• OnlineproviderdirectoryonmyCigna.com

• CallthenumberlocatedonyourIDcardto:

– UsetheDentalOfficeLocatorviaSpeechRecognition

– SpeaktoaCustomerServiceRepresentative

EMERGENCY:Ifyouhaveadentalemergencyasdefinedinyourgroup’splandocuments,contactyourNetworkGeneralDentistassoonaspossible.IfyouareoutofyourserviceareaorunabletocontactyourNetworkOffice,emergencycarecanberenderedbyanylicenseddentist.Definitivetreatment(e.g.,rootcanal)isnotconsideredemergencycareandshouldbeperformedorreferredbyyourNetworkGeneralDentist.Consultyourgroup’splandocumentsforacompletedefinitionofdentalemergency,youremergencybenefitandalistingofExclusionsandLimitations.

Documents

Cigna Dental Care DHMO) Patient Charge Schedule€¦ · Not all Network Dentists perform all listed services and it is suggested to check with your Network Dentist in advance of receiving