• 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.

92255 856662 02/13 C15V9

C15V9

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(duringregularlyscheduledhours)–Nootherservicesperformed

$5.00

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)

(C15V9)

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cigna dental care® patient cHarge scHedule

Code Procedure Description Patient Charge

D0170 Reevaluation–Limited,problemfocused(notpostoperativevisit)

$0.00

D0180 Comprehensiveperiodontalevaluation–Neworestablishedpatient

$0.00

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

D0273 X-rays(bitewings)–3radiographicimages $0.00

D0274 X-rays(bitewings)–4radiographicimages $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 $0.00

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

(C15V9)

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cigna dental care® patient cHarge scHedule

Code Procedure Description Patient Charge

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 $10.00

D1352 Preventiveresinrestorationinamoderatetohighcariesriskpatient–Permanenttooth

$10.00

D1510 Spacemaintainer–Fixed–Unilateral $35.00

D1515 Spacemaintainer–Fixed–Bilateral $35.00

D1520 Spacemaintainer–Removable–Unilateral $35.00

D1525 Spacemaintainer–Removable–Bilateral $35.00

D1550 Recementationofspacemaintainer $10.00

Restorative (fillings, including polishing)

D2140 Amalgam–1surface,primaryorpermanent $10.00

D2150 Amalgam–2surfaces,primaryorpermanent $12.00

D2160 Amalgam–3surfaces,primaryorpermanent $14.00

D2161 Amalgam–4ormoresurfaces,primaryorpermanent $14.00

(C15V9)

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cigna dental care® patient cHarge scHedule

Code Procedure Description Patient Charge

D2330 Resin-basedcomposite–1surface,anterior $15.00

D2331 Resin-basedcomposite–2surfaces,anterior $15.00

D2332 Resin-basedcomposite–3surfaces,anterior $15.00

D2335 Resin-basedcomposite–4ormoresurfacesorinvolvingincisalangle,anterior

$17.00

D2391 Resin-basedcomposite–1surface,posterior $55.00

D2392 Resin-basedcomposite–2surfaces,posterior $65.00

D2393 Resin-basedcomposite–3surfaces,posterior $85.00

D2394 Resin-basedcomposite–4ormoresurfaces,posterior $100.00

Crown and bridge – All charges for crowns and bridges (fixed partial dentures) are per unit (each replacement or supporting tooth equals 1 unit). For single crowns, retainer (“abutment”) crowns, and pontics: The charges below include the cost of predominantly base and noble metal alloys. You may be charged up to these additional amounts, based on the type of material the dentist uses for your restoration. • No more than $100.00 per tooth for any high noble metal alloys, titanium or

titanium alloys • No more than $150.00 per tooth for any porcelain fused to metal (only on

molar teeth)• Porcelain/ceramic substrate crowns on molar teeth are not covered

Inaddition,youmaybechargeduptotheseadditionalamounts.• Nomorethan$100.00pertoothifanindirectlyfabricated

(“cast”)postandcoreismadeofhighnoblemetalalloy• Nomorethan$150.00pertoothforcrowns,inlays,onlays,

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

D2510 Inlay–Metallic–1surface $45.00

D2520 Inlay–Metallic–2surfaces $50.00

D2530 Inlay–Metallic–3ormoresurfaces $55.00

(C15V9)

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cigna dental care® patient cHarge scHedule

Code Procedure Description Patient Charge

D2542 Onlay–Metallic–2surfaces $55.00

D2543 Onlay–Metallic–3surfaces $60.00

D2544 Onlay–Metallic–4ormoresurfaces $65.00

D2710 Crown–Resin,laboratory $85.00

D2720 Crown–Resinwithhighnoblemetal $150.00

D2721 Crown–Resinwithpredominantlybasemetal $150.00

D2722 Crown–Resinwithnoblemetal $150.00

D2740 Crown–Porcelain/ceramicsubstrate $150.00

D2750 Crown–Porcelainfusedtohighnoblemetal $150.00

D2751 Crown–Porcelainfusedtopredominantlybasemetal $150.00

D2752 Crown–Porcelainfusedtonoblemetal $150.00

D2780 Crown–3/4casthighnoblemetal $150.00

D2781 Crown–3/4castpredominantlybasemetal $150.00

D2782 Crown–3/4castnoblemetal $150.00

D2790 Crown–Fullcasthighnoblemetal $150.00

D2791 Crown–Fullcastpredominantlybasemetal $150.00

D2792 Crown–Fullcastnoblemetal $150.00

D2794 Crown–Titanium $150.00

D2910 Recementinlay–Onlayorpartialcoveragerestoration $10.00

D2920 Recementcrown $10.00

D2930 Prefabricatedstainlesssteelcrown–Primarytooth $5.00

D2931 Prefabricatedstainlesssteelcrown–Permanenttooth $5.00

D2932 Prefabricatedresincrown $25.00

D2933 Prefabricatedstainlesssteelcrownwithresinwindow $25.00

D2940 ProtectiveRestoration $25.00

D2950 Corebuildup–Includinganypins $50.00

D2951 Pinretention–Pertooth–Inadditiontorestoration $25.00

(C15V9)

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cigna dental care® patient cHarge scHedule

Code Procedure Description Patient Charge

D2952 Postandcore–Inadditiontocrown,indirectlyfabricated $25.00

D2953 Eachadditionalcastpost–Sametooth $25.00

D2954 Prefabricatedpostandcore–Inadditiontocrown–Basemetalpost

$50.00

D2957 Eachadditionalprefabricatedpost–Sametooth–Basemetalpost

$25.00

D2970 Temporarycrown–Fracturedtooth $25.00

D2980 Crownrepair,necessitatedbyrestorativematerialfailure $25.00

D6210 Pontic–Casthighnoblemetal $150.00

D6211 Pontic–Castpredominantlybasemetal $150.00

D6212 Pontic–Castnoblemetal $150.00

D6240 Pontic–Porcelainfusedtohighnoblemetal $150.00

D6241 Pontic–Porcelainfusedtopredominantlybasemetal $150.00

D6242 Pontic–Porcelainfusedtonoblemetal $150.00

D6250 Pontic–Resinwithhighnoblemetal $150.00

D6251 Pontic–Resinwithpredominantlybasemetal $150.00

D6252 Pontic–Resinwithnoblemetal $150.00

D6602 Inlay–Casthighnoblemetal,2surfaces $150.00

D6603 Inlay–Casthighnoblemetal,3ormoresurfaces $150.00

D6610 Onlay–Casthighnoblemetal,2surfaces $150.00

D6611 Onlay–Casthighnoblemetal,3ormoresurfaces $150.00

D6720 Crown–Resinwithhighnoblemetal $150.00

D6721 Crown–Resinwithpredominantlybasemetal $150.00

D6722 Crown–Resinwithnoblemetal $150.00

D6750 Crown–Porcelainfusedtohighnoblemetal $150.00

D6751 Crown–Porcelainfusedtopredominantlybasemetal $150.00

D6752 Crown–Porcelainfusedtonoblemetal $150.00

D6780 Crown–3/4casthighnoblemetal $150.00

(C15V9)

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cigna dental care® patient cHarge scHedule

Code Procedure Description Patient Charge

D6781 Crown–3/4castpredominantlybasemetal $150.00

D6782 Crown–3/4castnoblemetal $150.00

D6790 Crown–Fullcasthighnoblemetal $150.00

D6791 Crown–Fullcastpredominantlybasemetal $150.00

D6792 Crown–Fullcastnoblemetal $150.00

D6794 Crown–Titanium $150.00

D6930 Recementfixedpartialdenture $15.00

D6940 Stressbreaker $25.00

Endodontics (root canal treatment, excluding final restorations)

D3110 Pulpcap–Direct(excludingfinalrestoration) $6.00

D3120 Pulpcap–Indirect(excludingfinalrestoration) $6.00

D3220 Pulpotomy–Removalofpulp,notpartofarootcanal $8.00

D3221 Pulpaldebridement(nottobeusedwhenrootcanalisdoneonthesameday)

$15.00

D3222 Partialpulpotomyforapexogenesis–Permanenttoothwithincompleterootdevelopment

$8.00

D3230 Pulpaltherapy(resorbablefilling)–Anterior,primarytooth(excludingfinalrestoration)

$15.00

D3240 Pulpaltherapy(resorbablefilling)–Posterior,primarytooth(excludingfinalrestoration)

$15.00

D3310 Anteriorrootcanal–Permanenttooth(excludingfinalrestoration)

$60.00

D3320 Bicuspidrootcanal–Permanenttooth(excludingfinalrestoration)

$105.00

D3330 Molarrootcanal–Permanenttooth(excludingfinalrestoration)

$160.00

D3346 Retreatmentofpreviousrootcanaltherapy–Anterior $70.00

D3347 Retreatmentofpreviousrootcanaltherapy–Bicuspid $120.00

D3348 Retreatmentofpreviousrootcanaltherapy–Molar $170.00

(C15V9)

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cigna dental care® patient cHarge scHedule

Code Procedure Description Patient Charge

D3410 Apicoectomy/periradicularsurgery–Anterior $60.00

D3421 Apicoectomy/periradicularsurgery–Bicuspid(firstroot) $60.00

D3425 Apicoectomy/periradicularsurgery–Molar(firstroot) $60.00

D3426 Apicoectomy/periradicularsurgery(eachadditionalroot) $0.00

D3430 Retrogradefilling–Perroot $60.00

D3450 Rootamputationperroot(notcoveredinconjunctionwithprocedureD3920)

$0.00

Periodontics – Includes postoperative evaluations and treatment under a local anesthetic

D4210 Gingivectomyorgingivoplasty–4ormoreteethperquadrant

$125.00

D4211 Gingivectomyorgingivoplasty–1to3teethperquadrant $25.00

D4212 Gingivectomyorgingivoplastytoallowaccessforrestorativeprocedure,pertooth

$25.00

D4240 Gingivalflap(includingrootplaning)–4ormoreteethperquadrant

$125.00

D4241 Gingivalflap(includingrootplaning)–1to3teethperquadrant

$65.00

D4260 Osseoussurgery–4ormoreteethperquadrant $250.00

D4261 Osseoussurgery–1to3teethperquadrant $125.00

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

$35.00

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

$20.00

D4355 Fullmouthdebridementtoenablecomprehensiveperiodontalevaluationanddiagnosis

$50.00

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

$20.00

(C15V9)

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cigna dental care® patient cHarge scHedule

Code Procedure Description Patient Charge

Prosthetics (removable tooth replacement – dentures) includes up to 4 adjustments within first 6 months after insertion. Characterization is considered an upgrade with maximum additional charge to the member of $225.00 per denture.

D5110 Fullupperdenture $200.00

D5120 Fulllowerdenture $200.00

D5130 Immediatefullupperdenture $225.00

D5140 Immediatefulllowerdenture $225.00

D5211 Upperpartialdenture–Resinbase(includingclasps,restsandteeth)

$200.00

D5212 Lowerpartialdenture–Resinbase(includingclasps,restsandteeth)

$200.00

D5213 Upperpartialdenture–Castmetalframework(includingclasps,restsandteeth)

$200.00

D5214 Lowerpartialdenture–Castmetalframework(includingclasps,restsandteeth)

$200.00

D5225 Upperpartialdenture–Flexiblebase(includingclasps,restsandteeth)

$200.00

D5226 Lowerpartialdenture–Flexiblebase(includingclasps,restsandteeth)

$200.00

D5410 Adjustcompletedenture–Upper $10.00

D5411 Adjustcompletedenture–Lower $10.00

D5421 Adjustpartialdenture–Upper $10.00

D5422 Adjustpartialdenture–Lower $10.00

Repairs to prosthetics

D5510 Repairbrokencompletedenturebase $25.00

D5520 Replacemissingorbrokenteeth–Completedenture(eachtooth)

$15.00

D5610 Repairresindenturebase $25.00

D5620 Repaircastframework $25.00

(C15V9)

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cigna dental care® patient cHarge scHedule

Code Procedure Description Patient Charge

D5630 Repairorreplacebrokenclasp $25.00

D5640 Replacebrokenteeth–Pertooth $15.00

D5650 Addtoothtoexistingpartialdenture $15.00

D5660 Addclasptoexistingpartialdenture $15.00

Denture relining (limit 1 every 36 months)

D5710 Rebasecompleteupperdenture $60.00

D5711 Rebasecompletelowerdenture $60.00

D5720 Rebaseupperpartialdenture $60.00

D5721 Rebaselowerpartialdenture $60.00

D5730 Relinecompleteupperdenture–Chairside $25.00

D5731 Relinecompletelowerdenture–Chairside $25.00

D5740 Relineupperpartialdenture–Chairside $25.00

D5741 Relinelowerpartialdenture–Chairside $25.00

D5750 Relinecompleteupperdenture–Laboratory $60.00

D5751 Relinecompletelowerdenture–Laboratory $60.00

D5760 Relineupperpartialdenture–Laboratory $60.00

D5761 Relinelowerpartialdenture–Laboratory $60.00

Interim dentures (limited to initial placement of interim partial denture/stayplate to replace extracted anterior teeth during healing)

D5820 Interimpartialdenture–Upper $0.00

D5821 Interimpartialdenture–Lower $0.00

D5850 Tissueconditioning–Upper $20.00

D5851 Tissueconditioning–Lower $20.00

(C15V9)

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cigna dental care® patient cHarge scHedule

Code Procedure Description Patient Charge

Implant/abutment supported prosthetics – All charges for crowns and bridges (fixed partial dentures) are per unit (each replacement on a supporting implant(s) equals 1 unit). Coverage for replacement of implant supported dentures is limited to 1 every 5 years. For single crowns, retainer (“abutment”) crowns, and pontics: The charges below include the cost of predominantly base and noble metal alloys. You may be charged up to these additional amounts, based on the type of material the dentist uses for your restoration. • No more than $100.00 per tooth for any high noble metal alloys, titanium or

titanium alloys • No more than $150.00 per tooth for any porcelain fused to metal (only on

molar teeth)• Porcelain/ceramic substrate crowns on molar teeth are not covered

Inaddition,youmaybechargeduptotheseadditionalamounts.• Nomorethan$100.00pertoothifanindirectlyfabricated

(“cast”)postandcoreismadeofhighnoblemetalalloy• Nomorethan$150.00pertoothforcrowns,inlays,onlays,

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

D6053 Implant/abutmentsupportedremovabledentureforcompletelyedentulousarch

$500.00

D6054 Implant/abutmentsupportedremovabledentureforpartiallyedentulousarch

$500.00

D6058 Abutmentsupportedporcelain/ceramiccrown $450.00

D6059 Abutmentsupportedporcelainfusedtometalcrown(highnoblemetal)

$450.00

D6060 Abutmentsupportedporcelainfusedtometalcrown(predominantlybasemetal)

$450.00

D6061 Abutmentsupportedporcelainfusedtometalcrown(noblemetal)

$450.00

D6062 Abutmentsupportedcastmetalcrown(highnoblemetal) $450.00

(C15V9)

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cigna dental care® patient cHarge scHedule

Code Procedure Description Patient Charge

D6063 Abutmentsupportedcastmetalcrown(predominantlybasemetal)

$450.00

D6064 Abutmentsupportedcastmetalcrown(noblemetal) $450.00

D6065 Implantsupportedporcelain/ceramiccrown $450.00

D6066 Implantsupportedporcelainfusedtometalcrown(titanium,titaniumalloy,highnoblemetal)

$450.00

D6067 Implantsupportedmetalcrown(titanium,titaniumalloy,highnoblemetal)

$450.00

D6069 Abutmentsupportedretainerforporcelainfusedtometalfixedpartialdenture(highnoblemetal)

$450.00

D6070 Abutmentsupportedretainerforporcelainfusedtometalfixedpartialdenture(predominantlybasemetal)

$450.00

D6071 Abutmentsupportedretainerforporcelainfusedtometalfixedpartialdenture(noblemetal)

$450.00

D6072 Abutmentsupportedretainerforcastmetalfixedpartialdenture(highnoblemetal)

$450.00

D6073 Abutmentsupportedretainerforcastmetalfixedpartialdenture(predominantlybasemetal)

$450.00

D6074 Abutmentsupportedretainerforcastmetalfixedpartialdenture(noblemetal)

$450.00

D6077 Implantsupportedretainerforcastmetalfixedpartialdenture(titanium,titaniumalloy,highnoblemetal)

$450.00

D6078 Implant/abutmentsupportedfixeddentureforcompletelyedentulousarch

$500.00

D6079 Implant/abutmentsupportedfixeddentureforpartiallyedentulousarch

$500.00

D6092 Recementimplant/abutmentsupportedcrown $50.00

D6093 Recementimplant/abutmentsupportedfixedpartialdenture $55.00

D6094 Abutmentsupportedcrown(titanium) $450.00

D6194 Abutmentsupportedretainercrownforfixedpartialdenture(titanium)

$450.00

(C15V9)

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cigna dental care® patient cHarge scHedule

Code Procedure Description Patient Charge

Oral surgery (includes routine postoperative treatment) Surgical removal of impacted tooth – Not covered for ages below 15 unless pathology (disease) exists. Surgical removal of wisdom tooth/3rd molar for orthodontic reasons only is not covered.

D7111 Extractionofcoronalremnants–Deciduoustooth $10.00

D7140 Extraction,eruptedtoothorexposedroot–Elevationand/orforcepsremoval

$10.00

D7210 Surgicalremovaloferuptedtooth–Removalofboneand/orsectionoftooth

$22.00

D7220 Removalofimpactedtooth–Softtissue $40.00

D7230 Removalofimpactedtooth–Partiallybony $60.00

D7240 Removalofimpactedtooth–Completelybony $80.00

D7241 Removalofimpactedtooth–Completelybony,unusualcomplications(narrativerequired)

$80.00

D7250 Surgicalremovalofresidualtoothroots–Cuttingprocedure $0.00

D7251 Coronectomy–Intentionalpartialtoothremoval $60.00

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

$0.00

D7288 Brushbiopsy–Transepithelialsamplecollection $67.00

D7310 Alveoloplastyinconjunctionwithextractions–4ormoreteethortoothspacesperquadrant

$50.00

D7311 Alveoloplastyinconjunctionwithextractions–1to3teethortoothspacesperquadrant

$25.00

D7320 Alveoloplastynotinconjunctionwithextractions–4ormoreteethortoothspacesperquadrant

$70.00

D7321 Alveoloplastynotinconjunctionwithextractions–1to3teethortoothspacesperquadrant

$35.00

D7471 Removalofexostosis–Persite $0.00

D7510 Incisionanddrainageofabscess–Intraoralsofttissue $0.00

(C15V9)

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cigna dental care® patient cHarge scHedule

Code Procedure Description Patient Charge

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

$330.00

D7960 Frenulectomy–Alsoknownasfrenectomyorfrenotomy–Separateprocedurenotincidentaltoanotherprocedure

$0.00

Orthodontics (tooth movement) Orthodontic treatment (maximum lifetime 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

$275.00

D8060 Interceptiveorthodontictreatmentofthetransitionaldentition–Banding

$275.00

D8070 Comprehensiveorthodontictreatmentofthetransitionaldentition–Banding

$300.00

D8080 Comprehensiveorthodontictreatmentoftheadolescentdentition–Banding

$300.00

D8090 Comprehensiveorthodontictreatmentoftheadultdentition–Banding

$300.00

D8660 Pre-orthodontictreatmentvisit $40.00

D8670 Periodicorthodontictreatmentvisit–Aspartofcontract

Children–Upto19thbirthday:24-monthtreatmentfee $1,608.00Chargepermonthfor24months $67.00

Adults:24-monthtreatmentfee $1,800.00Chargepermonthfor24months $75.00

D8680 Orthodonticretention–Removalofappliances,constructionandplacementofretainer(s)

$300.00

D8999 Unspecifiedorthodonticprocedure–Byreport(orthodontictreatmentplanandrecords)

$150.00

(C15V9)

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cigna dental care® patient cHarge scHedule

Code Procedure Description Patient Charge

Adjunctive services

D9211 Regionalblockanesthesia $0.00

D9212 Trigeminaldivisionblockanesthesia $0.00

D9215 Localanesthesia $0.00

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 intravenous sedation when used for the purpose of anxiety control or patient management.

D9220 Generalanesthesia–First30minutes $160.00

D9221 Generalanesthesia–Eachadditional15minutes $75.00

D9241 IVconscioussedation–First30minutes $160.00

D9242 IVconscioussedation–Eachadditional15minutes $75.00

Emergency services

D9110 Palliative(emergency)treatmentofdentalpain–Minorprocedure

$5.00

D9440 Officevisit–Afterregularlyscheduledhours $20.00

(C15V9)

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cigna dental care® patient cHarge scHedule

Code Procedure Description Patient Charge

Miscellaneous services

D9941 Fabricationofathleticmouthguard(limit 1 per 12 months) $110.00

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

$165.00

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

(C15V9)

-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.

856662 02/13 © 2013 Cigna. Some content provided under license.