09 Series Standard Copay Patient Charge SchedulePlan effective 07/01/13 Page 3 CIGNA DENTAL CARE – PATIENT CHARGE SCHEDULE 09 Series – S tandard C opays isted on the following

Page 1b Limitations may be different for Arizona residents.

cigna dental care – Patient charge schedule

09 series – standard copays

Listed on the following pages of this Patient Charge Schedule at a Glance are charges to be paid directly to you by the member for specific procedures. In the case of any discrepancy between this “At a Glance” and the Patient Charge Schedule, the Patient Charge Schedule will prevail.

Different codes may be used to describe these covered procedures.

BC Series (for certain North Carolina Baxter employees)



Procedure Code1 G1-09 G1-V9 W1-09 W1-V9 L1-09 L1-V9 K1-09 K1-V9 F1-09 F1-V9 F7-09 F4-09 B1-09 K1I09 F1I09 B1I09

Office visit fee (Per patient, per office visit in addition to any other applicable patient charges)

Office visit fee $0 $5 $0 $5 $0 $5 $0 $5 $0 $5 $0 $0 $0 $0 $0 $0

Diagnostic/preventive – Oral evaluations are limited to a combined total of 4 of the following evaluations during a 12 consecutive month period: Periodic oral evaluations (D0120), comprehensive oral evaluations (D0150), comprehensive periodontal evaluations (D0180), and oral evaluations for patients under 3 years of age (D0145).

D9310 Consultation (diagnostic service provided by dentist or physician other than requesting dentist or physician)

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D9430 Office visit for observation – No other services performed

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D9450 Case presentation – Detailed and extensive treatment planning

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D0120 Periodic oral evaluation – Established patient b

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D0140 Limited oral evaluation – Problem focused

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D0145 Oral evaluation for a patient under 3 years of age and counseling with primary caregiver b

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D0150 Comprehensive oral evaluation – New or established patient b

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

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b Limitations may be different for Arizona residents. ■ Limitations may be different for Texas residents.


Diagnostic/preventive (continued)

D0160 Detailed and extensive oral evaluation – problem focused, by report (limit 2 per calendar year; only covered in conjunction with temporomandibular joint (TMJ) evaluation)

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D0170 Reevaluation – Limited, problem focused (not postoperative visit)

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D0180 Comprehensive periodontal evaluation – New or established patient b

$70 $70 $43 $43 $45 $45 $33 $33 $40 $40 $34 $18 $18 $33 $40 $18

D0210 X-rays intraoral – Complete series of radiographic images (limit 1 every 3 years) ■ b

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D0220 X-rays intraoral – Periapical – First radiographic image

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D0230 X-rays intraoral – Periapical – Each additional radiographic image

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D0240 X-rays intraoral – Occlusal radiographic image

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D0270 X-rays (bitewing) – Single radiographic image

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Plan effective 07/01/13

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D0272 X-rays (bitewings) – 2 radiographic images

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0


$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0


$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D0277 X-rays (bitewings, vertical) – 7 to 8 radiographic images

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D0330 X-rays (panoramic radiographic image) – (limit 1 every 3 years) ■ b

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D0364 Cone beam CT capture and interpretation with limited field of view – less than one whole jaw (only covered in conjunction with the surgical placement of an implant; limit of a total of only one D0364, D0365, D0366 or D0367 per calendar year)

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$200 $200 $200

Page 4







D0365 Cone beam CT capture and interpretation with field of view of one full dental arch – mandible (only covered in conjunction with the surgical placement of an implant; limit of a total of only one D0364, D0365, D0366 or D0367 per calendar year)

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$220 $220 $220

D0366 Cone beam CT capture and interpretation with field of view of one full dental arch – maxilla, with or without cranium (only covered in conjunction with the surgical placement of an implant; limit of a total of only one D0364, D0365, D0366 or D0367 per calendar year)

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$220 $220 $220

D0367 Cone beam CT capture and interpretation with field of view of both jaws, with or with-out cranium (only covered in conjunction with the surgical placement of an implant; limit of a total of only one D0364, D0365, D0366 or D0367 per calendar year)

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$240 $240 $240


Page 5







D0368 Cone beam CT capture and interpretation for TMJ series including two or more exposures (limit 1 per calendar year; only covered in conjunction with temporomandibular joint (TMJ) evaluation)

$240 $240 $240 $240 $240 $240 $240 $240 $240 $240 $240 $240 $240 $240 $240 $240

D0431 Oral cancer screening using a special light source

$50 $50 $50 $50 $50 $50 $50 $50 $50 $50 $50 $50 $50 $50 $50 $50

D0460 Pulp vitality tests $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14

D0470 Diagnostic casts $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D0472 Pathology report – Gross examination of lesion (only when tooth related)

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D0473 Pathology report – Microscopic examination of lesion (only when tooth related)

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D0474 Pathology report – Microscopic examination of lesion and area (only when tooth related)

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

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D1110 Prophylaxis (cleaning) – Adult (limit 2 per calendar year) ■ b

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Additional prophylaxis (cleaning) – In addition to the 2 prophylaxes (cleanings) allowed per calendar year

$45 $45 $45 $45 $45 $45 $45 $45 $45 $45 $45 $45 $45 $45 $45 $45

D1120 Prophylaxis (cleaning) – Child (limit 2 per calendar year) ■ b

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Additional prophylaxis (cleaning) – In addition to the 2 prophylaxes (cleanings) allowed per calendar year

$30 $30 $30 $30 $30 $30 $30 $30 $30 $30 $30 $30 $30 $30 $30 $30

D1206 Topical application of fluoride varnish – (limit 2 per calendar year). There is a combined limit of a total of 2 D1206s and/or D1208s per calendar year. ■ b

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Additional topical application of fluoride varnish in addition to any combination of two (2) D1206s (topical application of fluoride varnish) and/or D1208s (topical application of fluoride) per calendar year.

$15 $15 $15 $15 $15 $15 $15 $15 $15 $15 $15 $15 $15 $15 $15 $15


Page 7







D1208 Topical application of fluoride (limit 2 per calendar year) There is a combined limit of a total of 2 D1208s and/or D1206s per calendar year.

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Additional topical application of fluoride – In addition to any combination of two (2) D1206s (topical applications of fluoride varnish) and/or D1208s (topical application of fluoride) per calendar year

$15 $15 $15 $15 $15 $15 $15 $15 $15 $15 $15 $15 $15 $15 $15 $15

D1330 Oral hygiene instructions $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D1351 Sealant – Per tooth $17 $17 $17 $17 $17 $17 $12 $12 $0 $0 $0 $0 $0 $12 $0 $0

D1352 Preventive resin restoration in a moderate to high caries risk patient – Permanent tooth

$17 $17 $17 $17 $17 $17 $12 $12 $0 $0 $0 $0 $0 $12 $0 $0

D1510 Space maintainer – Fixed – Unilateral

$110 $110 $110 $110 $110 $110 $110 $110 $0 $0 $0 $0 $0 $110 $0 $0

D1515 Space maintainer – Fixed – Bilateral

$170 $170 $170 $170 $170 $170 $170 $170 $0 $0 $0 $0 $0 $170 $0 $0

D1555 Removal of fixed space maintainer

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

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Restorative (fillings, including polishing)

D2140 Amalgam – 1 surface, primary or permanent

$23 $23 $17 $17 $6 $6 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D2150 Amalgam – 2 surfaces, primary or permanent

$28 $28 $22 $22 $6 $6 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D2160 Amalgam – 3 surfaces, primary or permanent

$33 $33 $28 $28 $12 $12 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D2161 Amalgam – 4 or more surfaces, primary or permanent

$40 $40 $35 $35 $18 $18 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D2330 Resin-based composite – 1 surface, anterior

$33 $33 $22 $22 $6 $6 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D2331 Resin-based composite – 2 surfaces, anterior

$40 $40 $29 $29 $13 $13 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D2332 Resin-based composite – 3 surfaces, anterior

$47 $47 $35 $35 $18 $18 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D2335 Resin-based composite – 4 or more surfaces or involving incisal angle, anterior

$88 $88 $88 $88 $88 $88 $88 $88 $88 $88 $88 $88 $88 $88 $88 $88

D2390 Resin-based composite crown, anterior

$140 $140 $115 $115 $88 $88 $88 $88 $59 $59 $54 $59 $37 $88 $59 $37

D2391 Resin-based composite – 1 surface, posterior

$47 $47 $47 $47 $47 $47 $47 $47 $47 $47 $47 $47 $47 $47 $47 $47

D2392 Resin-based composite – 2 surfaces, posterior

$59 $59 $59 $59 $59 $59 $59 $59 $59 $59 $59 $59 $59 $59 $59 $59






♦ Limitations may be different for California residents.


Restorative (fillings, including polishing) (continued)

D2393 Resin-based composite – 3 surfaces, posterior

$82 $82 $82 $82 $82 $82 $82 $82 $82 $82 $82 $82 $82 $82 $82 $82

D2394 Resin-based composite – 4 or more surfaces, posterior

$115 $115 $115 $115 $115 $115 $115 $115 $115 $115 $115 $115 $115 $115 $115 $115

Crown and bridge – All charges for crown and bridge (fixed partial denture) are per unit (each replacement or supporting tooth equals 1 unit). Coverage for replacement of crowns and bridges is limited to 1 every 5 years. ♦

Per tooth charge for crowns, inlays, on-lays, post and cores, and veneers for same day in-office CAD/CAM (ceramic) services. Same day in-office CAD/CAM (ceramic) services refer to dental restorations that are created in the dental office by the use of a digital impression and an in-office CAD/CAM milling machine.

$150 $150 $150 $150 $150 $150 $150 $150 $150 $150 $150 $150 $150 $150 $150 $150

D2510 Inlay – Metallic – 1 surface $435 $435 $430 $430 $380 $380 $410 $410 $350 $350 $325 $350 $245 $410 $350 $245

D2520 Inlay – Metallic – 2 surfaces $435 $435 $430 $430 $380 $380 $410 $410 $350 $350 $325 $350 $245 $410 $350 $245

D2530 Inlay – Metallic – 3 or more surfaces

$435 $435 $430 $430 $380 $380 $410 $410 $350 $350 $325 $350 $245 $410 $350 $245

D2542 Onlay – Metallic – 2 surfaces $505 $505 $490 $490 $440 $440 $470 $470 $400 $400 $370 $400 $215 $470 $400 $215

D2543 Onlay – Metallic – 3 surfaces $505 $505 $490 $490 $440 $440 $470 $470 $400 $400 $370 $400 $215 $470 $400 $215

D2544 Onlay – Metallic – 4 or more surfaces

$505 $505 $490 $490 $440 $440 $470 $470 $400 $400 $370 $400 $215 $470 $400 $215

D2710 Crown – Resin-based composite (Indirect) b

Procedure covered in AZ only

$265 $265 $260 $260 $230 $230 $245 $245 $210 $210 $190 $210 $125 $245 $210 $125

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b Limitations may be different for Arizona residents.





Crown and bridge ♦ (continued)

D2712 Crown – 3/4 resin-based composite (indirect) b


$380 $380 $370 $370 $330 $330 $355 $355 $300 $300 $275 $300 $180 $355 $300 $180

D2720 Crown – Resin with high noble metal b Procedure covered in AZ only

$390 $390 $380 $380 $340 $340 $365 $365 $310 $310 $285 $310 $185 $365 $310 $185

D2721 Crown – Resin Based with Predominantly Base Metal b


$345 $345 $335 $335 $300 $300 $325 $325 $270 $270 $255 $270 $150 $325 $270 $150

D2722 Crown – Resin with noble metal b Procedure covered in AZ only

$365 $365 $355 $355 $325 $325 $345 $345 $290 $290 $270 $290 $180 $345 $290 $180

D2740 Crown – Porcelain/ceramic substrate

$520 $520 $515 $515 $460 $460 $490 $490 $415 $415 $380 $415 $240 $490 $415 $240

D2750 Crown – Porcelain fused to high noble metal

$480 $480 $470 $470 $420 $420 $450 $450 $380 $380 $350 $380 $230 $450 $380 $230

D2751 Crown – Porcelain fused to predominantly base metal

$425 $425 $415 $415 $370 $370 $400 $400 $335 $335 $315 $335 $185 $400 $335 $185

D2752 Crown – Porcelain fused to noble metal

$450 $450 $440 $440 $400 $400 $425 $425 $355 $355 $335 $355 $220 $425 $355 $220

D2780 Crown – 3/4 cast high noble metal

$490 $490 $480 $480 $430 $430 $460 $460 $390 $390 $360 $390 $235 $460 $390 $235

D2781 Crown – 3/4 cast predominantly base metal

$435 $435 $425 $425 $380 $380 $410 $410 $345 $345 $325 $345 $190 $410 $345 $190









D2782 Crown – 3/4 cast noble metal $460 $460 $450 $450 $410 $410 $435 $435 $365 $365 $345 $365 $225 $435 $365 $225

D2783 Crown – 3/4 Porcelain/Ceramic b Procedure covered in AZ only

$520 $520 $515 $515 $460 $460 $490 $490 $415 $415 $380 $415 $240 $490 $415 $240

D2790 Crown – Full cast high noble metal

$490 $490 $480 $480 $430 $430 $460 $460 $390 $390 $360 $390 $235 $460 $390 $235

D2791 Crown – Full cast predominantly base metal

$435 $435 $425 $425 $380 $380 $410 $410 $345 $345 $325 $345 $190 $410 $345 $190

D2792 Crown – Full cast noble metal $460 $460 $450 $450 $410 $410 $435 $435 $365 $365 $345 $365 $225 $435 $365 $225

D2794 Crown – Titanium $490 $490 $480 $480 $430 $430 $460 $460 $390 $390 $360 $390 $235 $460 $390 $235

D2799 Provisional Crown b Procedure covered in AZ only

$140 $140 $135 $135 $120 $120 $130 $130 $110 $110 $100 $110 $65 $130 $110 $65

D2910 Recement inlay – Onlay or partial coverage restoration

$43 $43 $43 $43 $12 $12 $43 $43 $12 $12 $12 $12 $12 $43 $12 $12

D2915 Recement cast or prefabricated post and core

$43 $43 $43 $43 $12 $12 $43 $43 $12 $12 $12 $12 $12 $43 $12 $12

D2920 Recement crown $43 $43 $43 $43 $12 $12 $43 $43 $12 $12 $12 $12 $12 $43 $12 $12

D2929 Prefabricated porcelain/ceramic crown – Primary tooth

$155 $155 $155 $155 $145 $145 $165 $165 $115 $115 $97 $115 $76 $165 $115 $76

D2930 Prefabricated stainless steel crown – Primary tooth

$110 $110 $105 $105 $92 $92 $105 $105 $12 $12 $12 $12 $12 $105 $12 $12

D2931 Prefabricated stainless steel crown – Permanent tooth

$110 $110 $105 $105 $92 $92 $105 $105 $12 $12 $12 $12 $12 $105 $12 $12

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D2932 Prefabricated resin crown $135 $135 $130 $130 $120 $120 $135 $135 $110 $110 $92 $110 $56 $135 $110 $56

D2933 Prefabricated stainless steel crown with resin window

$155 $155 $155 $155 $145 $145 $165 $165 $115 $115 $97 $115 $76 $165 $115 $76

D2934 Prefabricated esthetic coated stainless steel crown – Primary tooth

$155 $155 $155 $155 $145 $145 $165 $165 $115 $115 $97 $115 $76 $165 $115 $76

D2940 Protective restoration $24 $24 $15 $15 $13 $13 $13 $13 $13 $13 $13 $13 $13 $13 $13 $13

D2950 Core buildup – Including any pins

$125 $125 $105 $105 $97 $97 $135 $135 $92 $92 $92 $94 $44 $135 $92 $44

D2951 Pin retention – Per tooth – In addition to restoration

$29 $29 $23 $23 $18 $18 $13 $13 $19 $19 $19 $19 $13 $13 $19 $13

D2952 Post and core – In addition to crown, indirectly fabricated

$170 $170 $165 $165 $150 $150 $165 $165 $135 $135 $125 $135 $71 $165 $135 $71

D2954 Prefabricated post and core – In addition to crown

$140 $140 $140 $140 $125 $125 $135 $135 $115 $115 $97 $115 $61 $135 $115 $61

D2960 Labial veneer (resin laminate) – Chairside

$130 $130 $105 $105 $105 $105 $94 $94 $110 $110 $110 $110 $110 $94 $110 $110

D6210 Pontic – Cast high noble metal $480 $480 $470 $470 $420 $420 $450 $450 $380 $380 $350 $380 $230 $450 $380 $230

D6211 Pontic – Cast predominantly base metal

$435 $435 $425 $425 $380 $380 $410 $410 $345 $345 $325 $345 $190 $410 $345 $190

D6212 Pontic – Cast noble metal $460 $460 $450 $450 $410 $410 $435 $435 $365 $365 $345 $365 $225 $435 $365 $225

D6214 Pontic – Titanium $490 $490 $480 $480 $430 $430 $460 $460 $390 $390 $360 $390 $235 $460 $390 $235

D6240 Pontic – Porcelain fused to high noble metal

$480 $480 $470 $470 $420 $420 $450 $450 $380 $380 $350 $380 $230 $450 $380 $230


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D6241 Pontic – Porcelain fused to predominantly base metal

$435 $435 $425 $425 $380 $380 $410 $410 $345 $345 $325 $345 $190 $410 $345 $190

D6242 Pontic – Porcelain fused to noble metal

$460 $460 $450 $450 $410 $410 $435 $435 $365 $365 $345 $365 $225 $435 $365 $225

D6245 Pontic – Porcelain/ceramic $480 $480 $470 $470 $425 $425 $455 $455 $380 $380 $355 $380 $210 $455 $380 $210

D6602 Inlay – Cast high noble metal, 2 surfaces

$470 $470 $460 $460 $420 $420 $450 $450 $390 $390 $360 $390 $235 $450 $390 $235

D6603 Inlay – Cast high noble metal, 3 or more surfaces

$490 $490 $480 $480 $430 $430 $460 $460 $390 $390 $360 $390 $235 $460 $390 $235

D6604 Inlay – Cast predominantly base metal, 2 surfaces

$415 $415 $405 $405 $370 $370 $390 $390 $345 $345 $325 $345 $190 $390 $345 $190

D6605 Inlay – Cast predominantly base metal, 3 or more surfaces

$425 $425 $415 $415 $370 $370 $400 $400 $335 $335 $325 $335 $190 $400 $335 $190

D6606 Inlay – Cast noble metal, 2 surfaces

$440 $440 $430 $430 $390 $390 $415 $415 $345 $345 $335 $345 $225 $415 $345 $225

D6607 Inlay – Cast noble metal, 3 or more surfaces

$440 $440 $440 $440 $400 $400 $425 $425 $355 $355 $345 $355 $225 $425 $355 $225

D6610 Onlay – Cast high noble metal, 2 surfaces

$470 $470 $460 $460 $430 $430 $440 $440 $390 $390 $360 $390 $235 $440 $390 $235

D6611 Onlay – Cast high noble metal, 3 or more surfaces

$490 $490 $480 $480 $430 $430 $460 $460 $390 $390 $360 $390 $235 $460 $390 $235

D6612 Onlay – Cast predominantly base metal, 2 surfaces

$415 $415 $405 $405 $370 $370 $390 $390 $335 $335 $315 $335 $190 $390 $335 $190

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D6613 Onlay – Cast predominantly base metal, 3 or more surfaces

$425 $425 $415 $415 $370 $370 $400 $400 $335 $335 $315 $335 $190 $400 $335 $190

D6614 Onlay – Cast noble metal, 2 surfaces

$440 $440 $430 $430 $390 $390 $415 $415 $355 $355 $335 $355 $220 $415 $355 $220

D6615 Onlay – Cast noble metal, 3 or more surfaces

$450 $450 $450 $450 $410 $410 $435 $435 $365 $365 $345 $365 $225 $435 $365 $225

D6624 Inlay – Titanium $480 $480 $470 $470 $420 $420 $450 $450 $380 $380 $350 $380 $230 $450 $380 $230

D6634 Onlay – Titanium $480 $480 $470 $470 $420 $420 $450 $450 $380 $380 $350 $380 $230 $450 $380 $230

D6740 Crown – Porcelain/ceramic $530 $530 $525 $525 $470 $470 $500 $500 $425 $425 $390 $425 $245 $500 $425 $245

D6750 Crown – Porcelain fused to high noble metal

$490 $490 $480 $480 $430 $430 $460 $460 $390 $390 $360 $390 $235 $460 $390 $235

D6751 Crown – Porcelain fused to predominantly base metal

$435 $435 $425 $425 $380 $380 $410 $410 $345 $345 $325 $345 $190 $410 $345 $190

D6752 Crown – Porcelain fused to noble metal

$460 $460 $450 $450 $410 $410 $435 $435 $365 $365 $345 $365 $225 $435 $365 $225

D6780 Crown – 3/4 cast high noble metal

$490 $490 $480 $480 $430 $430 $460 $460 $390 $390 $360 $390 $235 $460 $390 $235

D6781 Crown – 3/4 cast predominantly base metal

$435 $435 $425 $425 $380 $380 $410 $410 $345 $345 $325 $345 $190 $410 $345 $190

D6782 Crown – 3/4 cast noble metal $460 $460 $450 $450 $410 $410 $435 $435 $365 $365 $345 $365 $225 $435 $365 $225

D6790 Crown – Full cast high noble metal

$490 $490 $480 $480 $430 $430 $460 $460 $390 $390 $360 $390 $235 $460 $390 $235


Page 15








D6791 Crown – Full cast predominantly base metal

$435 $435 $425 $425 $380 $380 $410 $410 $345 $345 $325 $345 $190 $410 $345 $190

D6792 Crown – Full cast noble metal $460 $460 $450 $450 $410 $410 $435 $435 $365 $365 $345 $365 $225 $435 $365 $225

D6794 Crown – Titanium $490 $490 $480 $480 $430 $430 $460 $460 $390 $390 $360 $390 $235 $460 $390 $235

Complex rehabilitation – Additional charge per unit for multiple crown units/complex rehabilitation (6 or more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit) ♦

$135 $135 $135 $135 $135 $135 $135 $135 $135 $135 $135 $135 $135 $135 $135 $135

D6930 Recement fixed partial denture $65 $65 $64 $64 $12 $12 $61 $61 $12 $12 $12 $12 $12 $61 $12 $12

Endodontics (root canal treatment, excluding final restorations)

D3110 Pulp cap – Direct (excluding final restoration)

$38 $38 $38 $38 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14

D3120 Pulp cap – Indirect (excluding final restoration)

$38 $38 $38 $38 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14

D3220 Pulpotomy – Removal of pulp, not part of a root canal

$97 $97 $87 $87 $89 $89 $72 $72 $21 $21 $21 $21 $21 $72 $21 $21

D3221 Pulpal debridement (not to be used when root canal is done on the same day)

$110 $110 $87 $87 $83 $83 $72 $72 $21 $21 $21 $21 $21 $72 $21 $21

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Endodontics (continued)

D3222 Partial pulpotomy for apexogenesis – Permanent tooth with incomplete root development

$110 $110 $87 $87 $89 $89 $72 $72 $21 $21 $21 $21 $21 $72 $21 $21

D3310 Anterior root canal – Permanent tooth (excluding final restoration)

$375 $375 $330 $330 $275 $275 $210 $210 $12 $12 $12 $12 $12 $210 $12 $12

D3320 Bicuspid root canal – Permanent tooth (excluding final restoration)

$445 $445 $390 $390 $320 $320 $245 $245 $31 $31 $31 $31 $31 $245 $31 $31

D3330 Molar root canal – Permanent tooth (excluding final restoration)

$595 $595 $530 $530 $440 $440 $335 $335 $280 $280 $245 $280 $185 $335 $280 $185

D3331 Treatment of root canal obstruction – Nonsurgical access

$170 $170 $155 $155 $130 $130 $97 $97 $14 $14 $14 $14 $14 $97 $14 $14

D3332 Incomplete endodontic therapy – Inoperable, unrestorable or fractured tooth

$185 $185 $155 $155 $130 $130 $97 $97 $14 $14 $14 $14 $14 $97 $14 $14

D3333 Internal root repair of perforation defects

$175 $175 $155 $155 $130 $130 $97 $97 $14 $14 $14 $14 $14 $97 $14 $14

D3346 Retreatment of previous root canal therapy – Anterior

$535 $535 $470 $470 $395 $395 $300 $300 $14 $14 $14 $14 $14 $300 $14 $14

D3347 Retreatment of previous root canal therapy – Bicuspid

$605 $605 $530 $530 $445 $445 $345 $345 $34 $34 $34 $34 $34 $345 $34 $34


Page 17






Endodontics (continued)

D3348 Retreatment of previous root canal therapy – Molar

$710 $710 $675 $675 $565 $565 $430 $430 $370 $370 $330 $375 $245 $430 $370 $245

D3410 Apicoectomy/periradicular surgery – Anterior

$440 $440 $415 $415 $360 $360 $275 $275 $155 $155 $14 $14 $14 $275 $155 $14

D3421 Apicoectomy/periradicular surgery – Bicuspid (first root)

$470 $470 $455 $455 $385 $385 $305 $305 $185 $185 $46 $47 $47 $305 $185 $47

D3425 Apicoectomy/periradicular surgery – Molar (first root)

$540 $540 $480 $480 $420 $420 $340 $340 $220 $220 $78 $80 $80 $340 $220 $80

D3426 Apicoectomy/periradicular surgery (each additional root)

$180 $180 $165 $165 $150 $150 $110 $110 $58 $58 $14 $14 $14 $110 $58 $14

D3430 Retrograde filling per root $130 $130 $115 $115 $89 $89 $72 $72 $40 $40 $14 $14 $14 $72 $40 $14

Periodontics (treatment of supporting tissues [gum and bone] of the teeth) periodontal regenerative procedures are limited to 1 regenerative procedure per site (or per tooth, if applicable), when covered on the patient charge schedule. The relevant procedure codes are D4263, D4264, D4266 and D4267. Localized delivery of antimicrobial agents is limited to 8 teeth (or 8 sites, if applicable) per 12 consecutive months when covered on the patient charge schedule.

D4210 Gingivectomy or gingivoplasty – 4 or more teeth per quadrant

$320 $320 $270 $270 $240 $240 $180 $180 $220 $220 $190 $120 $120 $180 $220 $120

D4211 Gingivectomy or gingivoplasty – 1 to 3 teeth per quadrant

$160 $160 $125 $125 $105 $105 $91 $91 $105 $105 $98 $60 $60 $91 $105 $60

D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth

$160 $160 $125 $125 $105 $105 $91 $91 $105 $105 $98 $60 $60 $91 $105 $60

D4240 Gingival flap (including root planing) – 4 or more teeth per quadrant

$365 $365 $330 $330 $305 $305 $235 $235 $280 $280 $245 $145 $135 $235 $280 $135

Page 18






Periodontics (continued)

D4241 Gingival flap (including root planing) – 1 to 3 teeth per quadrant

$220 $220 $180 $180 $165 $165 $125 $125 $155 $155 $130 $73 $75 $125 $155 $75

D4245 Apically positioned flap $365 $365 $310 $310 $280 $280 $235 $235 $280 $280 $245 $145 $135 $235 $280 $135

D4249 Clinical crown lengthening – Hard tissue

$405 $405 $365 $365 $340 $340 $255 $255 $315 $315 $265 $155 $100 $255 $315 $100

D4260 Osseous surgery – 4 or more teeth per quadrant

$640 $640 $595 $595 $540 $540 $400 $400 $465 $465 $415 $220 $185 $400 $465 $185

D4261 Osseous surgery – 1 to 3 teeth per quadrant

$385 $385 $350 $350 $310 $310 $240 $240 $270 $270 $245 $130 $115 $240 $270 $115

D4263 Bone replacement graft – First site in quadrant

$290 $290 $290 $290 $290 $290 $290 $290 $290 $290 $290 $290 $290 $290 $290 $290

D4264 Bone replacement graft – Each additional site in quadrant

$225 $225 $225 $225 $225 $225 $225 $225 $225 $225 $225 $225 $225 $225 $225 $225

D4266 Guided tissue regeneration – Resorbable barrier per site

$380 $380 $380 $380 $380 $380 $380 $380 $380 $380 $380 $380 $380 $380 $380 $380

D4267 Guided tissue regeneration – Nonresorbable barrier per site (includes membrane removal)

$430 $430 $430 $430 $430 $430 $430 $430 $430 $430 $430 $430 $430 $430 $430 $430

D4270 Pedicle soft tissue graft procedure

$495 $495 $425 $425 $415 $415 $300 $300 $380 $380 $325 $190 $115 $300 $380 $115

D4275 Soft tissue allograft $495 $495 $440 $440 $415 $415 $310 $310 $380 $380 $325 $190 $115 $310 $380 $115


Page 19





■ Limitations may be different for Texas residents.♦ Limitations may be different for California residents.



D4277 Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous (missing) tooth position in graft

$495 $495 $440 $440 $415 $415 $310 $310 $380 $380 $325 $190 $115 $310 $380 $115

D4278 Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous (missing) tooth position in same graft site

$250 $250 $220 $220 $210 $210 $155 $155 $190 $190 $165 $95 $60 $155 $190 $60

D4341 Periodontal scaling and root planing – 4 or more teeth per quadrant (limit 4 quadrants per consecutive 12 months) ■

$135 $135 $115 $115 $110 $110 $83 $83 $96 $96 $83 $49 $42 $83 $96 $42

D4342 Periodontal scaling and root planing – 1 to 3 teeth – per quadrant (limit 4 quadrants per consecutive 12 months) ■

$75 $75 $64 $64 $60 $60 $42 $42 $48 $48 $42 $30 $24 $42 $48 $24

D4355 Full mouth debridement to allow evaluation and diagnosis (1 per lifetime) ♦

$110 $110 $86 $86 $84 $84 $65 $65 $86 $86 $66 $47 $47 $65 $86 $47

D4381 Localized delivery of antimicrobial agents per tooth

$45 $45 $45 $45 $45 $45 $45 $45 $45 $45 $45 $45 $45 $45 $45 $45

Page 20





■ Limitations may be different for Texas residents.



D4910 Periodontal maintenance (limit 4 per calendar year) (only covered after active periodontal therapy) ■

$93 $93 $78 $78 $77 $77 $53 $53 $66 $66 $58 $34 $34 $53 $66 $34

Prosthetics (removable tooth replacement – dentures) includes up to 4 adjustments within first 6 months after insertion – Replacement limit 1 every 5 years.

D5110 Full upper denture $675 $675 $575 $575 $535 $535 $625 $625 $500 $500 $460 $505 $365 $625 $500 $365

D5120 Full lower denture $675 $675 $575 $575 $535 $535 $625 $625 $500 $500 $460 $505 $365 $625 $500 $365

D5130 Immediate full upper denture $705 $705 $615 $615 $575 $575 $680 $680 $550 $550 $500 $560 $405 $680 $550 $405

D5140 Immediate full lower denture $705 $705 $615 $615 $575 $575 $680 $680 $550 $550 $500 $560 $405 $680 $550 $405

D5211 Upper partial denture – Resin base (including clasps, rests and teeth)

$510 $510 $430 $430 $400 $400 $525 $525 $370 $370 $345 $370 $275 $525 $370 $275

D5212 Lower partial denture – Resin base (including clasps, rests and teeth)

$510 $510 $430 $430 $400 $400 $525 $525 $370 $370 $345 $370 $275 $525 $370 $275

D5213 Upper partial denture – Cast metal framework (including clasps, rests and teeth)

$780 $780 $670 $670 $625 $625 $715 $715 $575 $575 $530 $580 $425 $715 $575 $425

D5214 Lower partial denture – Cast metal framework (including clasps, rests and teeth)

$780 $780 $670 $670 $625 $625 $715 $715 $575 $575 $530 $580 $425 $715 $575 $425

D5225 Upper partial denture – Flexible base (including clasps, rests and teeth)

$580 $580 $460 $460 $430 $430 $605 $605 $400 $400 $375 $410 $305 $605 $400 $305


Page 21






Prosthetics (continued)

D5226 Lower partial denture – Flexible base (including clasps, rests and teeth)

$580 $580 $460 $460 $430 $430 $605 $605 $400 $400 $375 $410 $305 $605 $400 $305

D5410 Adjust complete denture – Upper

$43 $43 $38 $38 $38 $38 $43 $43 $39 $39 $33 $40 $27 $43 $39 $27

D5411 Adjust complete denture – Lower

$43 $43 $38 $38 $38 $38 $43 $43 $39 $39 $33 $40 $27 $43 $39 $27

D5421 Adjust partial denture – Upper $45 $45 $38 $38 $38 $38 $46 $46 $39 $39 $33 $40 $27 $46 $39 $27

D5422 Adjust partial denture – Lower $45 $45 $38 $38 $38 $38 $46 $46 $39 $39 $33 $40 $27 $46 $39 $27

Repairs to prosthetics

D5510 Repair broken complete denture base

$92 $92 $73 $73 $71 $71 $88 $88 $65 $65 $58 $66 $53 $88 $65 $53

D5520 Replace missing or broken teeth – Complete denture (each tooth)

$81 $81 $73 $73 $71 $71 $76 $76 $65 $65 $58 $66 $53 $76 $65 $53

D5610 Repair resin denture base $92 $92 $73 $73 $71 $71 $88 $88 $65 $65 $58 $66 $53 $88 $65 $53

D5630 Repair or replace broken clasp $115 $115 $92 $92 $88 $88 $110 $110 $85 $85 $77 $85 $66 $110 $85 $66

D5640 Replace broken teeth – Per tooth

$81 $81 $73 $73 $71 $71 $81 $81 $65 $65 $58 $66 $53 $81 $65 $53

D5650 Add tooth to existing partial denture

$92 $92 $73 $73 $71 $71 $88 $88 $65 $65 $58 $66 $53 $88 $65 $53

D5660 Add clasp to existing partial denture

$115 $115 $92 $92 $88 $88 $110 $110 $85 $85 $77 $85 $66 $110 $85 $66

Page 22






Denture relining (limit 1 every 36 months)

D5710 Rebase complete upper denture

$260 $260 $220 $220 $210 $210 $250 $250 $200 $200 $185 $205 $145 $250 $200 $145

D5711 Rebase complete lower denture

$260 $260 $220 $220 $210 $210 $250 $250 $200 $200 $185 $205 $145 $250 $200 $145

D5720 Rebase upper partial denture $260 $260 $220 $220 $210 $210 $250 $250 $200 $200 $185 $205 $145 $250 $200 $145

D5721 Rebase lower partial denture $260 $260 $220 $220 $210 $210 $250 $250 $200 $200 $185 $205 $145 $250 $200 $145

D5730 Reline complete upper denture – Chairside

$160 $160 $130 $130 $120 $120 $145 $145 $14 $14 $14 $14 $14 $145 $14 $14

D5731 Reline complete lower denture – Chairside

$160 $160 $130 $130 $120 $120 $145 $145 $14 $14 $14 $14 $14 $145 $14 $14

D5740 Reline upper partial denture – Chairside

$160 $160 $130 $130 $120 $120 $145 $145 $14 $14 $14 $14 $14 $145 $14 $14

D5741 Reline lower partial denture – Chairside

$160 $160 $130 $130 $120 $120 $145 $145 $14 $14 $14 $14 $14 $145 $14 $14

D5750 Reline complete upper denture – Laboratory

$220 $220 $195 $195 $185 $185 $210 $210 $170 $170 $155 $175 $130 $210 $170 $130

D5751 Reline complete lower denture – Laboratory

$220 $220 $195 $195 $185 $185 $210 $210 $170 $170 $155 $175 $130 $210 $170 $130

D5760 Reline upper partial denture – Laboratory

$220 $220 $195 $195 $185 $185 $210 $210 $170 $170 $155 $175 $130 $210 $170 $130

D5761 Reline lower partial denture – Laboratory

$220 $220 $195 $195 $185 $185 $210 $210 $170 $170 $155 $175 $130 $210 $170 $130


Page 23






Interim dentures (limit 1 every 5 years)

D5810 Interim complete denture – Upper

$405 $405 $330 $330 $305 $305 $315 $315 $290 $290 $270 $300 $220 $315 $290 $220

D5811 Interim complete denture – Lower

$405 $405 $330 $330 $305 $305 $315 $315 $290 $290 $270 $300 $220 $315 $290 $220

D5820 Interim partial denture – Upper $305 $305 $265 $265 $255 $255 $280 $280 $235 $235 $220 $240 $175 $280 $235 $175

D5821 Interim partial denture – Lower $305 $305 $265 $265 $255 $255 $280 $280 $235 $235 $220 $240 $175 $280 $235 $175

Implant Services – Surgical Placement of Implants (D6010, D6012, D6040, and D6050 have a limit of 1 implant per calendar year with a replacement of 1 per 10 years)

D6010 Surgical placement of implant body: Endosteal implant

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$1,025 $1,025 $1,025

D6012 Surgical placement of interim implant body for transitional prosthesis: Endosteal implant

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$390 $275 $355

D6040 Surgical placement: Eposteal implant

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$940 $665 $855

D6050 Surgical placement: Transosteal implant

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$920 $650 $835

D6055 Connecting bar – Implant supported or abutment supported (limit 1 per calendar year)

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$1,170 $825 $1,060

D6056 Prefabricated abutment – Includes modification and placement (limit 1 per calendar year)

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$355 $355 $355

Page 24






Implant Services (continued)

D6057 Custom fabricated abutment – Includes placement (limit 1 per calendar year)

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$455 $455 $455

D6080 Implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis (limit 1 per calendar year)

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$65 $45 $60

D6090 Repair implant supported prosthesis, by report (limit 1 per calendar year)

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$130 $90 $120

D6091 Replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment (limit 1 per calendar year)

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$60 $45 $55

D6095 Repair implant abutment, by report (limit 1 per calendar year)

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$130 $90 $115

D6100 Implant removal, by report (limit 1 per calendar year)

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$245 $175 $220


Page 25







Implant Services (continued)

D6101 Debridement of a periimplant defect and surface cleaning of exposed implant surfaces, in-cluding flap entry and closure (limit 1 per calendar year)

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$125 $155 $75

D6102 Debridement and osseous con-touring of a periimplant defect; includes surface cleaning of exposed implant surfaces and flap entry and closure (limit 1 per calendar year)

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$240 $270 $115

D6103 Bone graft for repair of periimplant defect – not including flap entry and closure or, when indicated, placement of a barrier membrane or biologic materials to aid in osseous regeneration (limit 1 per calendar year)

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$290 $290 $290

D6104 Bone graft at time of implant placement (limit 1 per calendar year)

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$290 $290 $290

D6190 Radiographic/surgical implant index, by report (limit 1 per calendar year)

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$165 $115 $150

Page 26







Implant/abutment supported prosthetics – All charges for crown and bridge (fixed partial denture) are per unit (each replacement on a supporting implant(s) equals 1 unit). Coverage for replacement of crowns and bridges and implant supported dentures is limited to 1 every 5 years. ♦

Per tooth charge for crowns, inlays, onlays, post and cores, and veneers for same day in-office CAD/CAM (ceramic) services. Same day in-office CAD/CAM (ceramic) services refer to dental restorations that are created in the dental office by the use of a digital impression and an in-office CAD/CAM milling machine.

$150 $150 $150 $150 $150 $150 $150 $150 $150 $150 $150 $150 $150 $150 $150 $150

D6053 Implant/abutment supported removable denture for completely edentulous arch

$975 $975 $875 $875 $835 $835 $925 $925 $800 $800 $760 $805 $665 $925 $800 $665

D6054 Implant/abutment supported removable denture for partially edentulous arch

$1,080 $1,080 $970 $970 $925 $925 $1,015 $1,015 $875 $875 $830 $880 $725 $1,015 $875 $725

D6058 Abutment supported porcelain/ceramic crown

$820 $820 $815 $815 $760 $760 $790 $790 $715 $715 $680 $715 $540 $790 $715 $540

D6059 Abutment supported porcelain fused to metal crown (high noble metal)

$780 $780 $770 $770 $720 $720 $750 $750 $680 $680 $650 $680 $530 $750 $680 $530

D6060 Abutment supported porcelain fused to metal crown (predominantly base metal)

$725 $725 $715 $715 $670 $670 $700 $700 $635 $635 $615 $635 $485 $700 $635 $485


Page 27







Implant/abutment supported prosthetics ♦ (continued)

D6061 Abutment supported porcelain fused to metal crown (noble metal)

$750 $750 $740 $740 $700 $700 $725 $725 $655 $655 $635 $655 $520 $725 $655 $520

D6062 Abutment supported cast metal crown (high noble metal)

$780 $780 $770 $770 $720 $720 $750 $750 $680 $680 $650 $680 $530 $750 $680 $530

D6063 Abutment supported cast metal crown (predominantly base metal)

$725 $725 $715 $715 $670 $670 $700 $700 $635 $635 $615 $635 $485 $700 $635 $485

D6064 Abutment supported cast metal crown (noble metal)

$750 $750 $740 $740 $700 $700 $725 $725 $655 $655 $635 $655 $520 $725 $655 $520

D6065 Implant supported porcelain/ceramic crown

$820 $820 $815 $815 $760 $760 $790 $790 $715 $715 $680 $715 $540 $790 $715 $540

D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal)

$780 $780 $770 $770 $720 $720 $750 $750 $680 $680 $650 $680 $530 $750 $680 $530

D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal)

$780 $780 $770 $770 $720 $720 $750 $750 $680 $680 $650 $680 $530 $750 $680 $530

D6068 Abutment supported retainer for porcelain/ceramic fixed partial denture

$820 $820 $815 $815 $760 $760 $790 $790 $715 $715 $680 $715 $540 $790 $715 $540

Page 28








D6069 Abutment supported retainer for porcelain fused to metal fixed partial denture (high noble metal)

$780 $780 $770 $770 $720 $720 $750 $750 $680 $680 $650 $680 $530 $750 $680 $530

D6070 Abutment supported retainer for porcelain fused to metal fixed partial denture (predominantly base metal)

$725 $725 $715 $715 $670 $670 $700 $700 $635 $635 $615 $635 $485 $700 $635 $485

D6071 Abutment supported retainer for porcelain fused to metal fixed partial denture (noble metal)

$750 $750 $740 $740 $700 $700 $725 $725 $655 $655 $635 $655 $520 $725 $655 $520

D6072 Abutment supported retainer for cast metal fixed partial denture (high noble metal)

$780 $780 $770 $770 $720 $720 $750 $750 $680 $680 $650 $680 $530 $750 $680 $530

D6073 Abutment supported retainer for cast metal fixed partial denture (predominantly base metal)

$725 $725 $715 $715 $670 $670 $700 $700 $635 $635 $615 $635 $485 $700 $635 $485

D6074 Abutment supported retainer for cast metal fixed partial denture (noble metal)

$750 $750 $740 $740 $700 $700 $725 $725 $655 $655 $635 $655 $520 $725 $655 $520

D6075 Implant supported retainer for ceramic fixed partial denture

$820 $820 $815 $815 $760 $760 $790 $790 $715 $715 $680 $715 $540 $790 $715 $540


Page 29








D6076 Implant supported retainer for porcelain fused to metal fixed partial denture (titanium, titanium alloy, high noble metal)

$780 $780 $770 $770 $720 $720 $750 $750 $680 $680 $650 $680 $530 $750 $680 $530

D6077 Implant supported retainer for cast metal fixed partial denture (titanium, titanium alloy, high noble metal)

$780 $780 $770 $770 $720 $720 $750 $750 $680 $680 $650 $680 $530 $750 $680 $530

D6078 Implant/abutment supported fixed denture for completely edentulous arch

$975 $975 $875 $875 $835 $835 $925 $925 $800 $800 $760 $805 $665 $925 $800 $665

D6079 Implant/abutment supported fixed denture for partially edentulous arch

$1,080 $1,080 $970 $970 $925 $925 $1,015 $1,015 $875 $875 $830 $880 $725 $1,015 $875 $725

D6092 Recement implant/abutment supported crown

$82 $82 $82 $82 $51 $51 $82 $82 $51 $51 $51 $51 $51 $82 $51 $51

D6093 Recement implant/abutment supported fixed partial denture

$103 $103 $103 $103 $51 $51 $99 $99 $51 $51 $51 $51 $51 $99 $51 $51

D6094 Abutment supported crown (titanium)

$780 $780 $770 $770 $720 $720 $750 $750 $680 $680 $650 $680 $530 $750 $680 $530

Page 30








D6194 Abutment supported retainer crown for fixed partial denture (titanium)

$780 $780 $770 $770 $720 $720 $750 $750 $680 $680 $650 $680 $530 $750 $680 $530

Complex rehabilitation on implant/abutment supported prosthetic procedures – Additional charge per unit for multiple crown units/complex rehabilitation (6 or more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit) ♦

$135 $135 $135 $135 $135 $135 $135 $135 $135 $135 $135 $135 $135 $135 $135 $135

Oral surgery (includes routine postoperative treatment) Surgical removal of impacted tooth – Not covered for ages below 15 unless pathology (disease) exists.

D7111 Extraction of coronal remnants – Deciduous tooth

$60 $60 $53 $53 $12 $12 $12 $12 $12 $12 $12 $12 $12 $12 $12 $12

D7140 Extraction, erupted tooth or exposed root – Elevation and/or forceps removal

$64 $64 $53 $53 $12 $12 $12 $12 $12 $12 $12 $12 $12 $12 $12 $12

D7210 Surgical removal of erupted tooth – Removal of bone and/or section of tooth

$155 $155 $115 $115 $89 $89 $53 $53 $21 $21 $21 $21 $21 $53 $21 $21

D7220 Removal of impacted tooth – Soft tissue

$165 $165 $125 $125 $71 $71 $46 $46 $21 $21 $21 $21 $21 $46 $21 $21

D7230 Removal of impacted tooth – Partially bony

$225 $225 $165 $165 $145 $145 $91 $91 $73 $73 $66 $73 $34 $91 $73 $34


Page 31






Oral surgery (continued)

D7240 Removal of impacted tooth – Completely bony

$300 $300 $230 $230 $185 $185 $115 $115 $120 $120 $115 $120 $61 $115 $120 $61

D7241 Removal of impacted tooth – Completely bony, unusual complications (narrative required)

$315 $315 $245 $245 $200 $200 $125 $125 $135 $135 $130 $135 $67 $125 $135 $67

D7250 Surgical removal of residual tooth roots – Cutting procedure

$155 $155 $115 $115 $89 $89 $53 $53 $21 $21 $21 $21 $21 $53 $21 $21

D7251 Coronectomy – Intentional partial tooth removal

$225 $225 $165 $165 $145 $145 $91 $91 $73 $73 $66 $73 $34 $91 $73 $34

D7260 Oroantral fistula closure $470 $470 $355 $355 $200 $200 $125 $125 $135 $135 $130 $135 $67 $125 $135 $67

D7261 Primary closure of a sinus perforation

$415 $415 $330 $330 $200 $200 $125 $125 $135 $135 $130 $135 $67 $125 $135 $67

D7270 Tooth stabilization of accidentally evulsed or displaced tooth

$210 $210 $180 $180 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14

D7280 Surgical access of an unerupted tooth (excluding wisdom teeth)

$270 $270 $210 $210 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14

D7283 Placement of device to facilitate eruption of impacted tooth

$68 $68 $49 $49 $8 $8 $8 $8 $8 $8 $8 $8 $8 $8 $8 $8

Page 32







D7285 Biopsy of oral tissue – Hard (bone, tooth) (tooth related – not allowed when in conjunction with another surgical procedure)

$225 $225 $180 $180 $145 $145 $78 $78 $91 $91 $78 $93 $60 $78 $91 $60

D7286 Biopsy of oral tissue – Soft (all others) (tooth related – not allowed when in conjunction with another surgical procedure)

$190 $190 $135 $135 $110 $110 $65 $65 $78 $78 $58 $80 $47 $65 $78 $47

D7287 Exfoliative cytological sample collection

$78 $78 $78 $78 $78 $78 $78 $78 $78 $78 $78 $78 $78 $78 $78 $78

D7288 Brush biopsy – Transepithelial sample collection

$78 $78 $78 $78 $78 $78 $78 $78 $78 $78 $78 $78 $78 $78 $78 $78

D7310 Alveoloplasty in conjunction with extractions – 4 or more teeth or tooth spaces per quadrant

$130 $130 $115 $115 $89 $89 $58 $58 $14 $14 $14 $14 $14 $58 $14 $14

D7311 Alveoloplasty in conjunction with extractions – 1 to 3 teeth or tooth spaces per quadrant

$68 $68 $56 $56 $45 $45 $33 $33 $8 $8 $8 $8 $8 $33 $8 $8

D7320 Alveoloplasty not in conjunc-tion with extractions – 4 or more teeth or tooth spaces per quadrant

$165 $165 $155 $155 $120 $120 $78 $78 $14 $14 $14 $14 $14 $78 $14 $14


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D7321 Alveoloplasty not in conjunction with extractions – 1 to 3 teeth or tooth spaces per quadrant

$81 $81 $74 $74 $64 $64 $40 $40 $8 $8 $8 $8 $8 $40 $8 $8

D7450 Removal of benign odontogenic cyst or tumor – Up to 1.25 cm

$260 $260 $195 $195 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14

D7451 Removal of benign odontogenic cyst or tumor – Greater than 1.25 cm

$260 $260 $195 $195 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14

D7471 Removal of lateral exostosis – Maxilla or mandible

$275 $275 $215 $215 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14

D7472 Removal of torus palatinus $275 $275 $215 $215 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14

D7473 Removal of torus mandibularis $275 $275 $215 $215 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14

D7485 Surgical reduction of osseous tuberosity

$165 $165 $155 $155 $120 $120 $78 $78 $14 $14 $14 $14 $14 $78 $14 $14

D7510 Incision and drainage of abscess – Intraoral soft tissue

$110 $110 $74 $74 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14

D7511 Incision and drainage of abscess – Intraoral soft tissue – Complicated

$165 $165 $115 $115 $20 $20 $20 $20 $20 $20 $20 $20 $20 $20 $20 $20

Page 34







D7880 Occlusal orthotic device, by report – (limit 1 per 24 months; only covered in conjunction with temporomandibular joint (TMJ) treatment)

$575 $575 $455 $455 $425 $425 $330 $330 $390 $390 $335 $190 $185 $330 $390 $185

D7951 Sinus augmentation with bone or bone substitutes via a lateral open approach (limit 1 per calendar year; only covered in conjunction with the surgical placement of implant)

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$850 $850 $850

D7952 Sinus augmentation via a vertical approach (limit 1 per calendar year; only covered in conjunction with the surgical placement of implant)

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$640 $640 $640

D7953 Bone replacement graft for ridge preservation – per site (limit 1 per calendar year; only covered in conjunction with the surgical placement of implant)

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

not cov’d

$100 $100 $100

D7960 Frenulectomy – Also known as frenectomy or frenotomy – Separate procedure not incidental to another procedure

$180 $180 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14 $14


Page 35







D7963 Frenuloplasty $220 $220 $20 $20 $20 $20 $20 $20 $20 $20 $20 $20 $20 $20 $20 $20

Orthodontics (tooth movement) Orthodontic treatment (maximum benefit of 24 months of interceptive and/or comprehensive treatment. Atypical cases or cases beyond 24 months require an additional payment by the patient.)

D8050 Interceptive orthodontic treatment of the primary dentition – Banding

$480 $480 $480 $480 $480 $480 $480 $480 $480 $480 $480 $480 $480 $480 $480 $480

D8060 Interceptive orthodontic treatment of the transitional dentition – Banding

$480 $480 $480 $480 $480 $480 $480 $480 $480 $480 $480 $480 $480 $480 $480 $480

D8070 Comprehensive orthodontic treatment of the transitional dentition – Banding

$500 $500 $500 $500 $500 $500 $500 $500 $500 $500 $500 $500 $500 $500 $500 $500

D8080 Comprehensive orthodontic treatment of the adolescent dentition – Banding

$515 $515 $515 $515 $515 $515 $515 $515 $515 $515 $515 $515 $515 $515 $515 $515

D8090 Comprehensive orthodontic treatment of the adult dentition – Banding

$515 $515 $515 $515 $515 $515 $515 $515 $515 $515 $515 $515 $515 $515 $515 $515

D8660 Pre-orthodontic treatment visit $66 $66 $66 $66 $67 $67 $67 $67 $68 $68 $68 $68 $50 $67 $68 $50

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Orthodontics (continued)

D8670 Periodic orthodontic treatment visit – As part of contractChildren – Up to 19th birthday:24-month treatment fee $2,472 $2,472 $2,472 $2,472 $2,280 $2,280 $2,040 $2,040 $2,184 $2,184 $1,560 $1,584 $1,584 $2,040 $2,184 $1,584Charge per month for 24 months

$103 $103 $103 $103 $95 $95 $85 $85 $91 $91 $65 $66 $66 $85 $91 $66

Adults:24-month treatment fee $3,384 $3,384 $3,336 $3,336 $3,000 $3,000 $2,376 $2,376 $2,904 $2,904 $2,304 $2,328 $2,328 $2,376 $2,904 $2,328Charge per month for 24 months

$141 $141 $139 $139 $125 $125 $99 $99 $121 $121 $96 $97 $97 $99 $121 $97

D8680 Orthodontic retention – Removal of appliances, construction and placement of retainer(s)

$345 $345 $345 $345 $345 $345 $345 $345 $345 $345 $345 $345 $345 $345 $345 $345

D8999 Unspecified orthodontic procedure – By report (orthodontic treatment plan and records)

$195 $195 $195 $195 $195 $195 $195 $195 $195 $195 $195 $195 $195 $195 $195 $195

General anesthesia/IV sedation – General anesthesia is covered when performed by an oral surgeon when medically necessary for covered procedures listed on the Patient Charge Schedule. IV sedation is covered when performed by a periodontist or oral surgeon when medically necessary for covered procedures listed on the Patient Charge Schedule. Plan limitation for this benefit is 1 hour per appointment. There is no coverage for general anesthesia or IV sedation when used for the purpose of anxiety control or patient management.D9220 General anesthesia – First 30

minutes$190 $190 $190 $190 $190 $190 $190 $190 $190 $190 $190 $190 $190 $190 $190 $190

D9221 General anesthesia – Each additional 15 minutes

$84 $84 $84 $84 $84 $84 $84 $84 $84 $84 $84 $84 $84 $84 $84 $84


Page 37






General anesthesia/IV sedation (continued)

D9241 IV conscious sedation – First 30 minutes

$190 $190 $190 $190 $190 $190 $190 $190 $190 $190 $190 $190 $190 $190 $190 $190

D9242 IV conscious sedation – Each additional 15 minutes

$73 $73 $73 $73 $73 $73 $73 $73 $73 $73 $73 $73 $73 $73 $73 $73

Emergency services

D9110 Palliative (emergency) treatment of dental pain – Minor procedure

$65 $65 $48 $48 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

D9440 Office visit – After regularly scheduled hours

$77 $77 $77 $77 $66 $66 $55 $55 $68 $68 $68 $68 $68 $55 $68 $68

Miscellaneous services

D9940 Occlusal guard – By report (limit 1 per 24 months)

$360 $360 $285 $285 $265 $265 $205 $205 $245 $245 $210 $120 $115 $205 $245 $115

D9941 Fabrication of athletic mouth-guard – (limit 1 per 12 months)

$110 $110 $110 $110 $110 $110 $110 $110 $110 $110 $110 $110 $110 $110 $110 $110

D9951 Occlusal adjustment – Limited $71 $71 $56 $56 $58 $58 $40 $40 $53 $53 $46 $34 $34 $40 $53 $34

D9952 Occlusal adjustment – Complete

$330 $330 $260 $260 $255 $255 $210 $210 $255 $255 $215 $125 $87 $210 $255 $87

D9975 External bleaching for home application, per arch; includes materials and fabrication of custom trays (all other methods of bleaching are not covered)

$165 $165 $165 $165 $165 $165 $165 $165 $165 $165 $165 $165 $165 $165 $165 $165

1. All CDT Codes are from Code on Dental Procedures and Nomenclature, a copyrighted publication provided by the American Dental Association. The American Dental Association does not endorse any codes which are not included in its current publication.

* Cigna Dental Care (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,” the “Tree of Life” logo, “GO YOU,” and “Cigna Dental Care” are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through 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 underwritten or administered 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.

868886 06/13 © 2013 Cigna. Some content provided under license.

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09 Series Standard Copay Patient Charge SchedulePlan effective 07/01/13 Page 3 CIGNA DENTAL CARE – PATIENT CHARGE SCHEDULE 09 Series – S tandard C opays isted on the following