cigna dental care® (*dHMO) patient cHarge scHeduleHMO+Patient+Charge+Sched… · • This Patient Charge Schedule applies only when covered dental services are ... (limit 2 per calendar

• ThisPatientChargeScheduleappliesonlywhencovereddentalservicesareperformedbyyourNetworkDentist,unlessotherwiseauthorizedbyCignaDentalasdescribedinyourplandocuments.NotallNetworkDentistsperformalllistedservicesanditissuggestedtocheckwithyourNetworkDentistinadvanceofreceivingservices.

• ThisPatientChargeScheduleappliestoSpecialtyCarewhenanappropriatereferralismadetoaNetworkSpecialtyPeriodontistorOralSurgeon.YoumustverifywiththeNetworkSpecialtyDentistthatyourtreatmentplanhasbeenauthorizedforpaymentbyCignaDental.PriorauthorizationisnotrequiredforspecialtyreferralsforPediatric,OrthodonticandEndodonticservices.YoumayselectaNetworkPediatricDentistforyourchildundertheageof7bycallingCustomerServiceat1.800.Cigna24togetalistofNetworkPediatricDentistsinyourarea.CoveragefortreatmentbyaPediatricDentistendsonyourchild’s7thbirthday;however,exceptionsformedicalreasonsmaybeconsideredonanindividualbasis.YourNetworkGeneralDentistwillprovidecareuponyourchild’s7thbirthday.

• ProceduresnotlistedonthisPatientChargeSchedulearenotcoveredandarethepatient’sresponsibilityatthedentist’susualfees.

• TheadministrationofIVsedation,generalanesthesia,and/ornitrousoxideisnotcoveredexceptasspecificallylistedonthisPatientChargeSchedule.Theapplicationoflocalanestheticiscoveredaspartofyourdentaltreatment.

• CignaDentalconsidersinfectioncontroland/orsterilizationtobeincidentaltoandpartofthechargesforservicesprovidedandnotseparatelychargeable.

92249 856608 02/13 W1-V9

W1-V9

cigna dental care® (*dHMO)

patient cHarge scHedule

ThisPatientChargeScheduleliststhebenefitsoftheDentalPlanincludingcoveredproceduresandpatientcharges.

Important Highlights

Subject to regulatory approval

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cigna dental care® patient cHarge scHedule

• ThisPatientChargeScheduleissubjecttoannualchangeinaccordancewiththetermsofthegroupagreement.

• ProcedureslistedonthePatientChargeSchedulearesubjecttotheplanlimitationsandexclusionsdescribedinyourplanbook/certificateofcoverageand/orgroupcontract.

• AllpatientchargesmustcorrespondtothePatientChargeScheduleineffectonthedatetheprocedureisinitiated.

• TheAmericanDentalAssociationmayperiodicallychangeCDTCodesordefinitions.Differentcodesmaybeusedtodescribethesecoveredprocedures.

Code Procedure Description Patient Charge

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

Officevisitfee $5.00

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(diagnosticserviceprovidedbydentistorphysicianotherthanrequestingdentistorphysician)

$0.00

D9430 Officevisitforobservation–Nootherservicesperformed $0.00

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(limit 2 per calendar year; only covered in conjunction with Temporomandibular Joint (TMJ) evaluation)

$0.00

Important Highlights (continued)

(W1-V9)

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D0170 Reevaluation–Limited,problemfocused(notpostoperativevisit)

$0.00

D0180 Comprehensiveperiodontalevaluation–Neworestablishedpatient

$43.00

D0210 X-raysintraoral–Completeseriesofradiographicimages(limit 1 every 3 years)

$0.00

D0220 X-raysintraoral–Periapical–Firstradiographicimage $0.00

D0230 X-raysintraoral–Periapical–Eachadditionalradiographicimage

$0.00

D0240 X-raysintraoral–Occlusalradiographicimage $0.00

D0270 X-rays(bitewing)–Singleradiographicimage $0.00

D0272 X-rays(bitewings)–2radiographicimages $0.00



D0277 X-rays(bitewings,vertical)–7to8radiographicimages $0.00

D0330 X-rays(panoramicradiographicimage)–(limit 1 every 3 years)

$0.00

D0368 ConebeamCTcaptureandinterpretationforTMJseriesincludingtwoormoreexposures(limit 1 per calendar year; only covered in conjunction with Temporomandibular Joint (TMJ) evaluation)

$240.00

D0431 Oralcancerscreeningusingaspeciallightsource $50.00

D0460 Pulpvitalitytests $14.00

D0470 Diagnosticcasts $0.00

D0472 Pathologyreport–Grossexaminationoflesion(onlywhentoothrelated)

$0.00

D0473 Pathologyreport–Microscopicexaminationoflesion(onlywhentoothrelated)

$0.00

D0474 Pathologyreport–Microscopicexaminationoflesionandarea(onlywhentoothrelated)

$0.00

D1110 Prophylaxis(cleaning)–Adult(limit 2 per calendar year) $0.00

Additionalprophylaxis(cleaning)–Inadditiontothe2prophylaxes(cleanings)allowedpercalendaryear

$45.00

(W1-V9)

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D1120 Prophylaxis(cleaning)–Child(limit 2 per calendar year) $0.00

Additionalprophylaxis(cleaning)–Inadditiontothe2prophylaxes(cleanings)allowedpercalendaryear

$30.00

D1206 Topicalapplicationoffluoridevarnish(limit 2 per calendar year). There is a combined limit of a total of 2 D1206s and/or D1208s per calendar year.

$0.00

Additionaltopicalapplicationoffluoridevarnish–Inadditiontoanycombinationoftwo(2)D1206s(topicalapplicationoffluoridevarnish)and/orD1208s(topicalapplicationoffluoride)percalendaryear.

$15.00

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

$0.00

Additionaltopicalapplicationoffluoride–Inadditiontoanycombinationoftwo(2)D1206s(topicalapplicationsoffluoridevarnish)and/orD1208s(topicalapplicationoffluoride)percalendaryear.

$15.00

D1330 Oralhygieneinstructions $0.00

D1351 Sealant–Pertooth $17.00

D1352 Preventiveresinrestorationinamoderatetohighcariesriskpatient–Permanenttooth

$17.00

D1510 Spacemaintainer–Fixed–Unilateral $110.00

D1515 Spacemaintainer–Fixed–Bilateral $170.00

D1555 Removaloffixedspacemaintainer $0.00

Restorative (fillings, including polishing)

D2140 Amalgam–1surface,primaryorpermanent $17.00

D2150 Amalgam–2surfaces,primaryorpermanent $22.00

D2160 Amalgam–3surfaces,primaryorpermanent $28.00

D2161 Amalgam–4ormoresurfaces,primaryorpermanent $35.00

D2330 Resin-basedcomposite–1surface,anterior $22.00

D2331 Resin-basedcomposite–2surfaces,anterior $29.00

(W1-V9)

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D2332 Resin-basedcomposite–3surfaces,anterior $35.00

D2335 Resin-basedcomposite–4ormoresurfacesorinvolvingincisalangle,anterior

$88.00

D2390 Resin-basedcompositecrown,anterior $115.00

D2391 Resin-basedcomposite–1surface,posterior $47.00

D2392 Resin-basedcomposite–2surfaces,posterior $59.00

D2393 Resin-basedcomposite–3surfaces,posterior $82.00

D2394 Resin-basedcomposite–4ormoresurfaces,posterior $115.00

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.

Pertoothchargeforcrowns,inlays,onlays,postandcores,andveneersifyourdentistusessamedayin-officeCAD/CAM(ceramic)services.Samedayin-officeCAD/CAM(ceramic)servicesrefertodentalrestorationsthatarecreatedinthedentalofficebytheuseofadigitalimpressionandanin-officeCAD/CAMmillingmachine.

$150.00

D2510 Inlay–Metallic–1surface $430.00

D2520 Inlay–Metallic–2surfaces $430.00

D2530 Inlay–Metallic–3ormoresurfaces $430.00

D2542 Onlay–Metallic–2surfaces $490.00

D2543 Onlay–Metallic–3surfaces $490.00

D2544 Onlay–Metallic–4ormoresurfaces $490.00

D2740 Crown–Porcelain/ceramicsubstrate $515.00

D2750 Crown–Porcelainfusedtohighnoblemetal $470.00

D2751 Crown–Porcelainfusedtopredominantlybasemetal $415.00

D2752 Crown–Porcelainfusedtonoblemetal $440.00

D2780 Crown–3/4casthighnoblemetal $480.00

D2781 Crown–3/4castpredominantlybasemetal $425.00

(W1-V9)

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D2782 Crown–3/4castnoblemetal $450.00

D2790 Crown–Fullcasthighnoblemetal $480.00

D2791 Crown–Fullcastpredominantlybasemetal $425.00

D2792 Crown–Fullcastnoblemetal $450.00

D2794 Crown–Titanium $480.00

D2910 Recementinlay–Onlayorpartialcoveragerestoration $43.00

D2915 Recementcastorprefabricatedpostandcore $43.00

D2920 Recementcrown $43.00

D2929 Prefabricatedporcelain/ceramiccrown–Primarytooth $155.00

D2930 Prefabricatedstainlesssteelcrown–Primarytooth $105.00

D2931 Prefabricatedstainlesssteelcrown–Permanenttooth $105.00

D2932 Prefabricatedresincrown $130.00

D2933 Prefabricatedstainlesssteelcrownwithresinwindow $155.00

D2934 Prefabricatedestheticcoatedstainlesssteelcrown–Primarytooth

$155.00

D2940 ProtectiveRestoration $15.00

D2950 Corebuildup–Includinganypins $105.00

D2951 Pinretention–Pertooth–Inadditiontorestoration $23.00

D2952 Postandcore–Inadditiontocrown,indirectlyfabricated $165.00

D2954 Prefabricatedpostandcore–Inadditiontocrown $140.00

D2960 Labialveneer(resinlaminate)–Chairside $105.00

D6210 Pontic–Casthighnoblemetal $470.00

D6211 Pontic–Castpredominantlybasemetal $425.00

D6212 Pontic–Castnoblemetal $450.00

D6214 Pontic–Titanium $480.00

D6240 Pontic–Porcelainfusedtohighnoblemetal $470.00

D6241 Pontic–Porcelainfusedtopredominantlybasemetal $425.00

(W1-V9)

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D6242 Pontic–Porcelainfusedtonoblemetal $450.00

D6245 Pontic–Porcelain/ceramic $470.00

D6602 Inlay–Casthighnoblemetal,2surfaces $460.00

D6603 Inlay–Casthighnoblemetal,3ormoresurfaces $480.00

D6604 Inlay–Castpredominantlybasemetal,2surfaces $405.00

D6605 Inlay–Castpredominantlybasemetal,3ormoresurfaces $415.00

D6606 Inlay–Castnoblemetal,2surfaces $430.00

D6607 Inlay–Castnoblemetal,3ormoresurfaces $440.00

D6610 Onlay–Casthighnoblemetal,2surfaces $460.00

D6611 Onlay–Casthighnoblemetal,3ormoresurfaces $480.00

D6612 Onlay–Castpredominantlybasemetal,2surfaces $405.00

D6613 Onlay–Castpredominantlybasemetal,3ormoresurfaces $415.00

D6614 Onlay–Castnoblemetal,2surfaces $430.00

D6615 Onlay–Castnoblemetal,3ormoresurfaces $450.00

D6624 Inlay–Titanium $470.00

D6634 Onlay–Titanium $470.00

D6740 Crown–Porcelain/ceramic $525.00

D6750 Crown–Porcelainfusedtohighnoblemetal $480.00

D6751 Crown–Porcelainfusedtopredominantlybasemetal $425.00

D6752 Crown–Porcelainfusedtonoblemetal $450.00

D6780 Crown–3/4casthighnoblemetal $480.00

D6781 Crown–3/4castpredominantlybasemetal $425.00

D6782 Crown–3/4castnoblemetal $450.00

D6790 Crown–Fullcasthighnoblemetal $480.00

D6791 Crown–Fullcastpredominantlybasemetal $425.00

D6792 Crown–Fullcastnoblemetal $450.00

D6794 Crown–Titanium $480.00

(W1-V9)

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Complexrehabilitation–Additionalchargeperunitformultiplecrownunits/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)

$135.00

D6930 Recementfixedpartialdenture $64.00

Endodontics (root canal treatment, excluding final restorations)

D3110 Pulpcap–Direct(excludingfinalrestoration) $38.00

D3120 Pulpcap–Indirect(excludingfinalrestoration) $38.00

D3220 Pulpotomy–Removalofpulp,notpartofarootcanal $87.00

D3221 Pulpaldebridement(nottobeusedwhenrootcanalisdoneonthesameday)

$87.00

D3222 Partialpulpotomyforapexogenesis–Permanenttoothwithincompleterootdevelopment

$87.00

D3310 Anteriorrootcanal–Permanenttooth(excludingfinalrestoration)

$330.00

D3320 Bicuspidrootcanal–Permanenttooth(excludingfinalrestoration)

$390.00

D3330 Molarrootcanal–Permanenttooth(excludingfinalrestoration)

$530.00

D3331 Treatmentofrootcanalobstruction–Nonsurgicalaccess $155.00

D3332 Incompleteendodontictherapy–Inoperable,unrestorableorfracturedtooth

$155.00

D3333 Internalrootrepairofperforationdefects $155.00

D3346 Retreatmentofpreviousrootcanaltherapy–Anterior $470.00

D3347 Retreatmentofpreviousrootcanaltherapy–Bicuspid $530.00

D3348 Retreatmentofpreviousrootcanaltherapy–Molar $675.00

D3410 Apicoectomy/periradicularsurgery–Anterior $415.00

D3421 Apicoectomy/periradicularsurgery–Bicuspid(firstroot) $455.00

D3425 Apicoectomy/periradicularsurgery–Molar(firstroot) $480.00

(W1-V9)

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D3426 Apicoectomy/periradicularsurgery(eachadditionalroot) $165.00

D3430 Retrogradefilling–Perroot $115.00

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 Gingivectomyorgingivoplasty–4ormoreteethperquadrant

$270.00

D4211 Gingivectomyorgingivoplasty–1to3teethperquadrant $125.00

D4212 Gingivectomyorgingivoplastytoallowaccessforrestorativeprocedure,pertooth

$125.00

D4240 Gingivalflap(includingrootplaning)–4ormoreteethperquadrant

$330.00

D4241 Gingivalflap(includingrootplaning)–1to3teethperquadrant

$180.00

D4245 Apicallypositionedflap $310.00

D4249 Clinicalcrownlengthening–Hardtissue $365.00

D4260 Osseoussurgery–4ormoreteethperquadrant $595.00

D4261 Osseoussurgery–1to3teethperquadrant $350.00

D4263 Bonereplacementgraft–Firstsiteinquadrant $290.00

D4264 Bonereplacementgraft–Eachadditionalsiteinquadrant $225.00

D4266 Guidedtissueregeneration–Resorbablebarrierpersite $380.00

D4267 Guidedtissueregeneration–Nonresorbablebarrierpersite(includesmembraneremoval)

$430.00

D4270 Pediclesofttissuegraftprocedure $425.00

D4275 Softtissueallograft $440.00

D4277 Freesofttissuegraftprocedure(includingdonorsitesurgery),firsttoothoredentulous(missing)toothpositioningraft

$440.00

(W1-V9)

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D4278 Freesofttissuegraftprocedure(includingdonorsitesurgery),eachadditionalcontiguoustoothoredentulous(missing) toothpositioninsamegraftsite

$220.00

D4341 Periodontalscalingandrootplaning–4ormoreteethperquadrant(limit 4 quadrants per consecutive 12 months)

$115.00

D4342 Periodontalscalingandrootplaning–1to3teethperquadrant(limit 4 quadrants per consecutive 12 months)

$64.00

D4355 Fullmouthdebridementtoallowevaluationanddiagnosis(1 per lifetime)

$86.00

D4381 Localizeddeliveryofantimicrobialagentspertooth $45.00

D4910 Periodontalmaintenance(limit 4 per calendar year) (only covered after active periodontal therapy)

$78.00

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

D5110 Fullupperdenture $575.00

D5120 Fulllowerdenture $575.00

D5130 Immediatefullupperdenture $615.00

D5140 Immediatefulllowerdenture $615.00

D5211 Upperpartialdenture–Resinbase(includingclasps,restsandteeth)

$430.00

D5212 Lowerpartialdenture–Resinbase(includingclasps,restsandteeth)

$430.00

D5213 Upperpartialdenture–Castmetalframework(includingclasps,restsandteeth)

$670.00

D5214 Lowerpartialdenture–Castmetalframework(includingclasps,restsandteeth)

$670.00

D5225 Upperpartialdenture–Flexiblebase(includingclasps,restsandteeth)

$460.00

D5226 Lowerpartialdenture–Flexiblebase(includingclasps,restsandteeth)

$460.00

D5410 Adjustcompletedenture–Upper $38.00

(W1-V9)

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D5411 Adjustcompletedenture–Lower $38.00

D5421 Adjustpartialdenture–Upper $38.00

D5422 Adjustpartialdenture–Lower $38.00

Repairs to prosthetics

D5510 Repairbrokencompletedenturebase $73.00

D5520 Replacemissingorbrokenteeth–Completedenture(eachtooth)

$73.00

D5610 Repairresindenturebase $73.00

D5630 Repairorreplacebrokenclasp $92.00

D5640 Replacebrokenteeth–Pertooth $73.00

D5650 Addtoothtoexistingpartialdenture $73.00

D5660 Addclasptoexistingpartialdenture $92.00

Denture relining (limit 1 every 36 months)

D5710 Rebasecompleteupperdenture $220.00

D5711 Rebasecompletelowerdenture $220.00

D5720 Rebaseupperpartialdenture $220.00

D5721 Rebaselowerpartialdenture $220.00

D5730 Relinecompleteupperdenture–Chairside $130.00

D5731 Relinecompletelowerdenture–Chairside $130.00

D5740 Relineupperpartialdenture–Chairside $130.00

D5741 Relinelowerpartialdenture–Chairside $130.00

D5750 Relinecompleteupperdenture–Laboratory $195.00

D5751 Relinecompletelowerdenture–Laboratory $195.00

D5760 Relineupperpartialdenture–Laboratory $195.00

D5761 Relinelowerpartialdenture–Laboratory $195.00

(W1-V9)

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Interim dentures (limit 1 every 5 years)

D5810 Interimcompletedenture–Upper $330.00

D5811 Interimcompletedenture–Lower $330.00

D5820 Interimpartialdenture–Upper $265.00

D5821 Interimpartialdenture–Lower $265.00

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.

Pertoothchargeforcrowns,inlays,onlays,postandcores,andveneersifyourdentistusessamedayin-officeCAD/CAM(ceramic)services.Samedayin-officeCAD/CAM(ceramic)servicesrefertodentalrestorationsthatarecreatedinthedentalofficebytheuseofadigitalimpressionandanin-officeCAD/CAMmillingmachine.

$150.00

D6053 Implant/abutmentsupportedremovabledentureforcompletelyedentulousarch

$875.00

D6054 Implant/abutmentsupportedremovabledentureforpartiallyedentulousarch

$970.00

D6058 Abutmentsupportedporcelain/ceramiccrown $815.00

D6059 Abutmentsupportedporcelainfusedtometalcrown(highnoblemetal)

$770.00

D6060 Abutmentsupportedporcelainfusedtometalcrown(predominantlybasemetal)

$715.00

D6061 Abutmentsupportedporcelainfusedtometalcrown(noblemetal)

$740.00

D6062 Abutmentsupportedcastmetalcrown(highnoblemetal) $770.00

D6063 Abutmentsupportedcastmetalcrown(predominantlybasemetal)

$715.00

D6064 Abutmentsupportedcastmetalcrown(noblemetal) $740.00

D6065 Implantsupportedporcelain/ceramiccrown $815.00

(W1-V9)

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D6066 Implantsupportedporcelainfusedtometalcrown(titanium,titaniumalloy,highnoblemetal)

$770.00

D6067 Implantsupportedmetalcrown(titanium,titaniumalloy,highnoblemetal)

$770.00

D6068 Abutmentsupportedretainerforporcelain/ceramicfixedpartialdenture

$815.00

D6069 Abutmentsupportedretainerforporcelainfusedtometalfixedpartialdenture(highnoblemetal)

$770.00

D6070 Abutmentsupportedretainerforporcelainfusedtometalfixedpartialdenture(predominantlybasemetal)

$715.00

D6071 Abutmentsupportedretainerforporcelainfusedtometalfixedpartialdenture(noblemetal)

$740.00

D6072 Abutmentsupportedretainerforcastmetalfixedpartialdenture(highnoblemetal)

$770.00

D6073 Abutmentsupportedretainerforcastmetalfixedpartialdenture(predominantlybasemetal)

$715.00

D6074 Abutmentsupportedretainerforcastmetalfixedpartialdenture(noblemetal)

$740.00

D6075 Implantsupportedretainerforceramicfixedpartialdenture $815.00

D6076 Implantsupportedretainerforporcelainfusedtometalfixedpartialdenture(titanium,titaniumalloy,highnoblemetal)

$770.00

D6077 Implantsupportedretainerforcastmetalfixedpartialdenture(titanium,titaniumalloy,highnoblemetal)

$770.00

D6078 Implant/abutmentsupportedfixeddentureforcompletelyedentulousarch

$875.00

D6079 Implant/abutmentsupportedfixeddentureforpartiallyedentulousarch

$970.00

D6092 Recementimplant/abutmentsupportedcrown $82.00

D6093 Recementimplant/abutmentsupportedfixedpartialdenture $103.00

D6094 Abutmentsupportedcrown(titanium) $770.00

(W1-V9)

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D6194 Abutmentsupportedretainercrownforfixedpartialdenture(titanium)

$770.00

Complexrehabilitationonimplant/abutmentsupportedprostheticprocedures–Additionalchargeperunitformultiplecrownunits/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)

$135.00

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

D7111 Extractionofcoronalremnants–Deciduoustooth $53.00

D7140 Extraction,eruptedtoothorexposedroot–Elevationand/orforcepsremoval

$53.00

D7210 Surgicalremovaloferuptedtooth–Removalofboneand/orsectionoftooth

$115.00

D7220 Removalofimpactedtooth–Softtissue $125.00

D7230 Removalofimpactedtooth–Partiallybony $165.00

D7240 Removalofimpactedtooth–Completelybony $230.00

D7241 Removalofimpactedtooth–Completelybony,unusualcomplications(narrativerequired)

$245.00

D7250 Surgicalremovalofresidualtoothroots–Cuttingprocedure $115.00

D7251 Coronectomy–Intentionalpartialtoothremoval $165.00

D7260 Oroantralfistulaclosure $355.00

D7261 Primaryclosureofasinusperforation $330.00

D7270 Toothstabilizationofaccidentallyevulsedordisplacedtooth $180.00

D7280 Surgicalaccessofanuneruptedtooth(excludingwisdomteeth)

$210.00

D7283 Placementofdevicetofacilitateeruptionofimpactedtooth $49.00

D7285 Biopsyoforaltissue–Hard(bone,tooth)(toothrelated–notallowedwheninconjunctionwithanothersurgicalprocedure)

$180.00

(W1-V9)

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D7286 Biopsyoforaltissue–Soft(allothers)(toothrelated–notallowedwheninconjunctionwithanothersurgicalprocedure)

$135.00

D7287 Exfoliativecytologicalsamplecollection $78.00

D7288 Brushbiopsy–Transepithelialsamplecollection $78.00

D7310 Alveoloplastyinconjunctionwithextractions–4ormoreteethortoothspacesperquadrant

$115.00

D7311 Alveoloplastyinconjunctionwithextractions–1to3teethortoothspacesperquadrant

$56.00

D7320 Alveoloplastynotinconjunctionwithextractions–4ormoreteethortoothspacesperquadrant

$155.00

D7321 Alveoloplastynotinconjunctionwithextractions–1to3teethortoothspacesperquadrant

$74.00

D7450 Removalofbenignodontogeniccystortumor–Upto1.25cm

$195.00

D7451 Removalofbenignodontogeniccystortumor–Greaterthan1.25cm

$195.00

D7471 Removaloflateralexostosis–Maxillaormandible $215.00

D7472 Removaloftoruspalatinus $215.00

D7473 Removaloftorusmandibularis $215.00

D7485 Surgicalreductionofosseoustuberosity $155.00

D7510 Incisionanddrainageofabscess–Intraoralsofttissue $74.00

D7511 Incisionanddrainageofabscess–Intraoralsofttissue–Complicated

$115.00

D7880 Occlusalorthoticdevice,byreport(limit 1 per 24 months; only covered in conjunction with Temporomandibular Joint (TMJ) treatment)

$455.00

D7960 Frenulectomy–Alsoknownasfrenectomyorfrenotomy–Separateprocedurenotincidentaltoanotherprocedure

$14.00

D7963 Frenuloplasty $20.00

(W1-V9)

-16-



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 Interceptiveorthodontictreatmentoftheprimarydentition–Banding

$480.00

D8060 Interceptiveorthodontictreatmentofthetransitionaldentition–Banding

$480.00

D8070 Comprehensiveorthodontictreatmentofthetransitionaldentition–Banding

$500.00

D8080 Comprehensiveorthodontictreatmentoftheadolescentdentition–Banding

$515.00

D8090 Comprehensiveorthodontictreatmentoftheadultdentition–Banding

$515.00

D8660 Pre-orthodontictreatmentvisit $66.00

D8670 Periodicorthodontictreatmentvisit–Aspartofcontract

Children–Upto19thbirthday:24-monthtreatmentfee $2,472.00Chargepermonthfor24months $103.00

Adults:24-monthtreatmentfee $3,336.00Chargepermonthfor24months $139.00

D8680 Orthodonticretention–Removalofappliances,constructionandplacementofretainer(s)

$345.00

D8999 Unspecifiedorthodonticprocedure–Byreport(orthodontictreatmentplanandrecords)

$195.00

(W1-V9)

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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 Generalanesthesia–First30minutes $190.00

D9221 Generalanesthesia–Eachadditional15minutes $84.00

D9241 IVconscioussedation–First30minutes $190.00

D9242 IVconscioussedation–Eachadditional15minutes $73.00

Emergency services

D9110 Palliative(emergency)treatmentofdentalpain–Minorprocedure

$48.00

D9440 Officevisit–Afterregularlyscheduledhours $77.00

Miscellaneous services

D9940 Occlusalguard–Byreport(limit 1 per 24 months) $285.00

D9941 Fabricationofathleticmouthguard(limit 1 per 12 months) $110.00

D9951 Occlusaladjustment–Limited $56.00

D9952 Occlusaladjustment–Complete $260.00

D9975 Externalbleachingforhomeapplication,perarch;includesmaterialsandfabricationofcustomtrays(all other methods of bleaching are not covered)

$165.00

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

(W1-V9)

-18-

After your enrollment is effective:CallthedentalofficeidentifiedinyourWelcomeKit.Ifyouwishtochangedentaloffices,atransfercanbearrangedatnochargebycallingCignaDentalatthetollfreenumberlistedonyourIDcardorplanmaterials.Multiplewaystolocatea*DHMONetworkGeneralDentist:

• OnlineproviderdirectoryatCigna.com

• OnlineproviderdirectoryonmyCigna.com

• CallthenumberlocatedonyourIDcardto:

– UsetheDentalOfficeLocatorviaSpeechRecognition

– SpeaktoaCustomerServiceRepresentative

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

* 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,” “Cigna Dental Care” and “GO YOU” 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 by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include 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. 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.

856608 02/13 © 2013 Cigna. Some content provided under license.

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cigna dental care® (*dHMO) patient cHarge scHeduleHMO+Patient+Charge+Sched… · • This Patient Charge Schedule applies only when covered dental services are ... (limit 2 per calendar