260125_Chapter_1E_-_Dental_COT_HMO_Patient_Change_Schedule_W1SV9_AZ.pdf

W1SV9

CIGNA DENTAL CARE® PLAN

PATIENT CHARGE SCHEDULE

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

Important Highlights

› This Patient Charge Schedule applies only when covered dental services are performed by your Network Dentist, unless otherwise authorized as described in your plan documents. Not all Network Dentists perform all listed services and it is suggested that you check with your Network Dentist in advance of receiving services.

› The dollar amounts listed on the Patient Charge Schedule are only applicable to treatment performed by your selected Network General Dentist. If you receive care from a Network Specialty Dentist, you are responsible to pay for that care. You are entitled to pay at the Contract Fees negotiated rather than the Network Specialty Dentists’ usual fees.

Under this plan, referrals and preauthorization for payment are not necessary for care received at a Network Specialty Dentist. The plan will not make payments toward this treatment.

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

› Infection control and/or sterilization are considered to be incidental to and part of the charges for services provided and not separately chargeable.

› This Patient Charge Schedule is subject to annual change in accordance with the terms of the group agreement.

› Procedures listed on the Patient Charge Schedule are subject to the plan limitations and exclusions described in your plan book/certificate of coverage and/or group contract.

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› All patient charges correspond to the Patient Charge Schedule in effect on the date the procedure is initiated.

› Current Dental Terminology ("CDT") codes are established by the American Dental Association (ADA) Council on Dental Benefit Programs in accordance with authority granted by the federal government under the Health Insurance and Portability and Accountability Act of 1996 (HIPAA) as the national terminology for reporting dental services, and are recognized as the industry standard. The ADA publishes CDT as part of a reference manual and may periodically change CDT Codes or definitions.

Different codes may be used to describe these covered procedures. The language in italics is intended to clarify the members’ benefit.

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CIGNA DENTAL CARE PLAN

PATIENT CHARGE SCHEDULE (W1SV9)

Important Highlights (Continued)

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

$5.00Office visit fee

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).

$0.00Consultation (diagnostic service provided by dentist or physician other than requesting dentist or physician)

D9310

$0.00Consultation with a medical health care professionalD9311

$0.00Office visit for observation – No other services performedD9430

$0.00Case presentation – Detailed and extensive treatment planningD9450

$0.00Periodic oral evaluation – Established patientD0120

$0.00Limited oral evaluation – Problem focusedD0140

$0.00Oral evaluation for a patient under 3 years of age and counseling with primary caregiver

D0145

$0.00Comprehensive oral evaluation – New or established patientD0150

$0.00Detailed and extensive oral evaluation - Problem focused, by report (limit 2 per calendar year; only covered in conjunction with Temporomandibular Joint (TMJ) evaluation)

D0160

$0.00Re-evaluation – Limited, problem focused (established patient;

not post-operative visit)

D0170

$0.00Re-evaluation – Post-operative office visitD0171

$43.00Comprehensive periodontal evaluation – New or established patient

D0180

$0.00X-rays intraoral – Complete series of radiographic images (limited to 1 D0210 or D0709 every 3 years)

D0210

$0.00X-rays intraoral – Periapical – First radiographic imageD0220

$0.00X-rays intraoral – Periapical – Each additional radiographic imageD0230

CIGNA DENTAL CARE PLAN

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$0.00X-rays intraoral – Occlusal radiographic imageD0240

$0.00X-rays extra-oral – 2D projection radiographic image created using a stationary radiation source, and detector

D0250

$0.00X-rays extra-oral posterior dental radiographic image (limit 1 D0251 or D0705 per calendar year)

D0251

$0.00X-rays (bitewing) – Single radiographic imageD0270

$0.00X-rays (bitewings) – 2 radiographic imagesD0272

$0.00X-rays (bitewings) – 3 radiographic imagesD0273

$0.00X-rays (bitewings) – 4 radiographic imagesD0274

$0.00X-rays (bitewings, vertical) – 7 to 8 radiographic imagesD0277

$0.00X-rays (panoramic radiographic image) – (limited to 1 D0330 or D0701 every 3 years) (when utilized for orthodontic services, see D8999)

D0330

$0.002D cephalometric radiographic image - Acquisition, measurement and analysis (when utilized for orthodontic services, see D8999)

D0340

$0.002D oral/facial photographic images obtained intra-orally or extra-orally (when utilized for orthodontic services, see D8999)

D0350

$0.003D photographic image (when utilized for orthodontic services, see D8999)

D0351

$240Cone beam CT capture and interpretation for TMJ series including two or more exposures (limit 1 per calendar year; only

D0368 covered in conjunction with Temporomandibular Joint (TMJ) evaluation)

$0.00Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report

D0391

$0.00Treatment simulation using 3D image volumeD0393

$0.00Digital subtraction of two or more images or image volumes of the same modality

D0394

$0.00Fusion of two or more 3D image volumes of one or more modalities

D0395

CIGNA DENTAL CARE PLAN

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$0.00Laboratory processing of microbial specimen to include culture and sensitivity studies, preparation, and transmission of written report

D0414

$50.00Oral cancer screening using a special light sourceD0431

$14.00Pulp vitality testsD0460

$0.00Diagnostic casts (when utilized for orthodontic services, see D8999)D0470

$0.00Pathology report – Gross examination of lesion (only when tooth related)

D0472

$0.00Pathology report – Microscopic examination of lesion (only when tooth related)

D0473

$0.00Pathology report – Microscopic examination of lesion and area (only when tooth related)

D0474

$0.00Non-ionizing diagnostic procedure capable of quantifying, monitoring and recording changes in structure of enamel, dentin and cementum

D0600

$0.00X-rays (panoramic radiographic image) – Image capture only (limited to 1 D0330 or D0701 every 3 years) (when utilized for orthodontic services, see D8999)

D0701

$0.002D cephalometric radiographic image – Image capture only (when utilized for orthodontic services, see D8999)

D0702

$0.002D oral/facial photographic image obtained intra-orally or extra-orally – Image capture only (when utilized for orthodontic services, see D8999)

D0703

$0.003D photographic image – Image capture only (when utilized for orthodontic services, see D8999)

D0704

$0.00X-rays extra-oral posterior dental radiographic image – Image capture only (limited to 1 D0251 or D0705 per calendar year)

D0705

$0.00X-rays intraoral – Occlusal radiographic image – Image capture only

D0706

$0.00X-rays intraoral – Periapical radiographic image – Image capture only

D0707

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$0.00X-rays intraoral – Bitewing radiographic image – Image capture only

D0708

$0.00X-rays intraoral – Complete series of radiographic images – Image capture only (limit 1 D0210 or D0709 every 3 years)

D0709

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

$45.00Additional prophylaxis (cleaning) – In addition to the 2 prophylaxes (cleanings) allowed per calendar year

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

$30.00Additional prophylaxis (cleaning) – In addition to the 2 prophylaxes (cleanings) allowed per calendar year

$0.00Topical 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.

D1206

$15.00Additional 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 - excluding varnish) per calendar year

$0.00Topical application of fluoride - Excluding varnish (limit 2 per calendar year) There is a combined limit of a total of 2 D1208s and/ or D1206s per calendar year.

D1208

$15.00Additional topical application of fluoride - Excluding varnish - In addition to any combination of two (2) D1206s (topical applications of fluoride varnish) and/or D1208s (topical application of fluoride - excluding varnish) per calendar year

$0.00Nutritional counseling for control of dental diseaseD1310

$0.00Oral hygiene instructionsD1330

$17.00Sealant – Per toothD1351

$17.00Preventive resin restoration in a moderate to high caries risk patient – Permanent tooth

D1352

$11.00Sealant repair – Per toothD1353

$0.00Application of caries arresting medicament - Per toothD1354

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$0.00Caries preventive medicament application – Per toothD1355

$110.00Space maintainer – Fixed - Unilateral - Per quadrantD1510

$170.00Space maintainer – Fixed – Bilateral, upperD1516

$170.00Space maintainer – Fixed – Bilateral, lowerD1517

$110.00Space maintainer – Removable - Unilateral - Per quadrantD1520

$170.00Space maintainer – Removable – Bilateral, upperD1526

$170.00Space maintainer – Removable – Bilateral, lowerD1527

$0.00Re-cement or re-bond bilateral space maintainer – UpperD1551

$0.00Re-cement or re-bond bilateral space maintainer – LowerD1552

$0.00Re-cement or re-bond unilateral space maintainer – Per quadrantD1553

$0.00Removal of fixed unilateral space maintainer – Per quadrantD1556

$0.00Removal of fixed bilateral space maintainer – UpperD1557

$0.00Removal of fixed bilateral space maintainer – LowerD1558

$121.00Distal shoe space maintainer – Fixed, Unilateral - Per quadrantD1575

Restorative (fillings - primary or permanent teeth, including polishing)

$17.00Amalgam – 1 surface, primary or permanentD2140

$22.00Amalgam – 2 surfaces, primary or permanentD2150

$28.00Amalgam – 3 surfaces, primary or permanentD2160

$35.00Amalgam – 4 or more surfaces, primary or permanentD2161

$22.00Resin-based composite – 1 surface, anteriorD2330

$29.00Resin-based composite – 2 surfaces, anteriorD2331

$35.00Resin-based composite – 3 surfaces, anteriorD2332

$88.00Resin-based composite – 4 or more surfaces or involving incisal angle, anterior

D2335

$115.00Resin-based composite crown, anteriorD2390

CIGNA DENTAL CARE PLAN

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$47.00Resin-based composite – 1 surface, posteriorD2391

$59.00Resin-based composite – 2 surfaces, posteriorD2392

$82.00Resin-based composite – 3 surfaces, posteriorD2393

$115.00Resin-based composite – 4 or more surfaces, posteriorD2394

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.

$150.00Additional charge per tooth/unit for crowns, inlays, onlays, post and cores, and veneers if your dentist uses 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.

$430.00Inlay – Metallic – 1 surfaceD2510

$430.00Inlay – Metallic – 2 surfacesD2520

$430.00Inlay – Metallic – 3 or more surfacesD2530

$490.00Onlay – Metallic – 2 surfacesD2542

$490.00Onlay – Metallic – 3 surfacesD2543

$490.00Onlay – Metallic – 4 or more surfacesD2544

$260.00Crown – Resin-based composite, indirectD2710

$370.00Crown – 3/4 resin-based composite, indirectD2712

$380.00Crown – Resin with high noble metalD2720

$335.00Crown – Resin with predominantly base metalD2721

$355.00Crown – Resin with noble metalD2722

$515.00Crown – Porcelain/ceramicD2740

$470.00Crown – Porcelain fused to high noble metalD2750

$415.00Crown – Porcelain fused to predominantly base metalD2751

$440.00Crown – Porcelain fused to noble metalD2752

CIGNA DENTAL CARE PLAN

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$470.00Crown - Porcelain fused to titanium and titanium alloysD2753

$480.00Crown – 3/4 cast high noble metalD2780

$425.00Crown – 3/4 cast predominantly base metalD2781

$450.00Crown – 3/4 cast noble metalD2782

$515.00Crown – 3/4 porcelain/ceramicD2783

$480.00Crown – Full cast high noble metalD2790

$425.00Crown – Full cast predominantly base metalD2791

$450.00Crown – Full cast noble metalD2792

$480.00Crown – Titanium and titanium alloysD2794

$135.00Interim crown (not to be used as a temporary crown for a routine prosthetic restoration)

D2799

$43.00Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration

D2910

$43.00Re-cement or re-bond indirectly fabricated or prefabricated post and core

D2915

$43.00Re-cement or re-bond crownD2920

$155.00Prefabricated porcelain/ceramic crown – Permanent toothD2928

$155.00Prefabricated porcelain/ceramic crown - Primary toothD2929

$105.00Prefabricated stainless steel crown – Primary toothD2930

$105.00Prefabricated stainless steel crown – Permanent toothD2931

$130.00Prefabricated resin crownD2932

$155.00Prefabricated stainless steel crown with resin windowD2933

$155.00Prefabricated esthetic coated stainless steel crown – Primary tooth

D2934

$15.00Protective restorationD2940

$15.00Interim therapeutic restoration - Primary dentitionD2941

$105.00Core buildup – Including any pinsD2950

CIGNA DENTAL CARE PLAN

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$23.00Pin retention – Per tooth – In addition to restorationD2951

$165.00Post and core – In addition to crown, indirectly fabricatedD2952

$140.00Prefabricated post and core – In addition to crownD2954

$105.00Labial veneer (resin laminate) – DirectD2960

$15.00Crown repair necessitated by restorative material failureD2980

$15.00Veneer repair necessitated by restorative material failureD2983

$470.00Pontic – Cast high noble metalD6210

$425.00Pontic – Cast predominantly base metalD6211

$450.00Pontic – Cast noble metalD6212

$480.00Pontic – Titanium and titanium alloysD6214

$470.00Pontic – Porcelain fused to high noble metalD6240

$425.00Pontic – Porcelain fused to predominantly base metalD6241

$450.00Pontic – Porcelain fused to noble metalD6242

$470.00Pontic – Porcelain fused to titanium and titanium alloysD6243

$470.00Pontic – Porcelain/ceramicD6245

$460.00Retainer inlay – Cast high noble metal, 2 surfacesD6602

$480.00Retainer inlay – Cast high noble metal, 3 or more surfacesD6603

$405.00Retainer inlay – Cast predominantly base metal, 2 surfacesD6604

$415.00Retainer inlay – Cast predominantly base metal, 3 or more surfaces

D6605

$430.00Retainer inlay – Cast noble metal, 2 surfacesD6606

$440.00Retainer inlay – Cast noble metal, 3 or more surfacesD6607

$460.00Retainer onlay – Cast high noble metal, 2 surfacesD6610

$480.00Retainer onlay – Cast high noble metal, 3 or more surfacesD6611

$405.00Retainer onlay – Cast predominantly base metal, 2 surfacesD6612

CIGNA DENTAL CARE PLAN

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$415.00Retainer onlay – Cast predominantly base metal, 3 or more surfaces

D6613

$430.00Retainer onlay – Cast noble metal, 2 surfacesD6614

$450.00Retainer onlay – Cast noble metal, 3 or more surfacesD6615

$470.00Retainer inlay – TitaniumD6624

$470.00Retainer onlay – TitaniumD6634

$525.00Retainer crown – Porcelain/ceramicD6740

$480.00Retainer crown – Porcelain fused to high noble metalD6750

$425.00Retainer crown – Porcelain fused to predominantly base metalD6751

$450.00Retainer crown – Porcelain fused to noble metalD6752

$480.00Retainer crown – Porcelain fused to titanium and titanium alloysD6753

$480.00Retainer crown – 3/4 cast high noble metalD6780

$425.00Retainer crown – 3/4 cast predominantly base metalD6781

$450.00Retainer crown – 3/4 cast noble metalD6782

$480.00Retainer crown - 3/4 titanium and titanium alloysD6784

$480.00Retainer crown – Full cast high noble metalD6790

$425.00Retainer crown – Full cast predominantly base metalD6791

$450.00Retainer crown – Full cast noble metalD6792

$480.00Retainer crown – Titanium and titanium alloysD6794

$64.00Re-cement or re-bond fixed partial dentureD6930

$135.00Complex rehabilitation – Additional charge per unit for multiple crown units/complex rehabilitation (6or more units of crown and/ or bridge in same treatment plan requires complex rehabilitation for each unit – ask your dentist for the guidelines)

Endodontics (root canal treatment, excluding final restorations)

$38.00Pulp cap – Direct (excluding final restoration)D3110

$38.00Pulp cap – Indirect (excluding final restoration)D3120

CIGNA DENTAL CARE PLAN

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$87.00Pulpotomy – Removal of pulp, not part of a root canalD3220

$87.00Pulpal debridement (not to be used when root canal is done on the same day)

D3221

$87.00Partial pulpotomy for apexogenesis – Permanent tooth with incomplete root development

D3222

$330.00Anterior root canal – Permanent tooth (excluding final restoration)

D3310

$390.00Premolar root canal – Permanent tooth (excluding final restoration)

D3320

$530.00Molar root canal – Permanent tooth (excluding final restoration)D3330

$155.00Treatment of root canal obstruction – Nonsurgical accessD3331

$155.00Incomplete endodontic therapy – Inoperable, unrestorable or fractured tooth

D3332

$155.00Internal root repair of perforation defectsD3333

$470.00Retreatment of previous root canal therapy – AnteriorD3346

$530.00Retreatment of previous root canal therapy – PremolarD3347

$675.00Retreatment of previous root canal therapy – MolarD3348

$415.00Apicoectomy/periradicular surgery – AnteriorD3410

$455.00Apicoectomy/periradicular surgery – Premolar (first root)D3421

$480.00Apicoectomy/periradicular surgery – Molar (first root)D3425

$165.00Apicoectomy/periradicular surgery (each additional root)D3426

$115.00Retrograde filling per rootD3430

$415.00Surgical repair of root resorption – AnteriorD3471

$415.00Surgical repair of root resorption – PremolarD3472

$415.00Surgical repair of root resorption – MolarD3473

$415.00Surgical exposure of root surface without apicoectomy or repair of root resorption – Anterior

D3501

CIGNA DENTAL CARE PLAN

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$415.00Surgical exposure of root surface without apicoectomy or repair of root resorption – Premolar

D3502

$415.00Surgical exposure of root surface without apicoectomy or repair of root resorption – Molar

D3503

$0.00Intraorifice barrierD3911

$415.00Decoronation or submergence of an erupted toothD3921

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. The use of any tools or equipment, including but not limited to handpieces, lasers, scalers, etc., is considered inclusive to the overall covered procedure listed on the Patient Charge Schedule, and cannot be separately charged.

$270.00Gingivectomy or gingivoplasty – 4 or more teeth per quadrantD4210

$125.00Gingivectomy or gingivoplasty – 1 to 3 teeth per quadrantD4211

$125.00Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth

D4212

$330.00Gingival flap (including root planing) – 4 or more teeth per quadrant

D4240

$180.00Gingival flap (including root planing) – 1 to 3 teeth per quadrantD4241

$310.00Apically positioned flapD4245

$365.00Clinical crown lengthening – Hard tissueD4249

$595.00Osseous surgery – 4 or more teeth per quadrantD4260

$350.00Osseous surgery – 1 to 3 teeth per quadrantD4261

$290.00Bone replacement graft – Retained natural tooth - First site in quadrant

D4263

$225.00Bone replacement graft – Retained natural tooth - Each additional site in quadrant

D4264

$380.00Guided tissue regeneration – Resorbable barrier per siteD4266

CIGNA DENTAL CARE PLAN

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$430.00Guided tissue regeneration – Nonresorbable barrier per site (includes membrane removal)

D4267

$425.00Pedicle soft tissue graft procedureD4270

$440.00Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft

D4275

$440.00Free soft tissue graft procedure (including recipient and donor surgical sites), first tooth, implant or edentulous (missing) tooth position in graft

D4277

$220.00Free soft tissue graft procedure (including recipient and donor surgical sites), each additional contiguous tooth, implant or edentulous (missing) tooth position in same graft site

D4278

$220.00Non-autogenous connective tissue graft procedure (including recipient surgical site and donor materials) – Each additional

D4285 contiguous tooth, implant or edentulous tooth position in same graft site

$115.00Periodontal scaling and root planing – 4 or more teeth per quadrant (limited to once per quadrant per consecutive 12 months)

D4341

$64.00Periodontal scaling and root planing – 1 to 3 teeth per quadrant (limited to once per quadrant per consecutive 12 months)

D4342

$0.00Scaling in presence of generalized moderate or severe gingival inflammation – Full mouth, after oral evaluation (limit 1 per calendar year)

D4346

$45.00Additional scaling in presence of generalized moderate or severe gingival inflammation – Full mouth, after oral evaluation (limit 2 per calendar year)

$86.00Full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (1 per lifetime, unless medically necessary)

D4355

$45.00Localized delivery of antimicrobial agents per toothD4381

$78.00Periodontal maintenance (limit 4 per calendar year) (only covered after active periodontal therapy)

D4910

CIGNA DENTAL CARE PLAN

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$78.00Additional periodontal maintenance procedures (beyond 4 per calendar year)

$0.00Periodontal charting for planning treatment of periodontal disease

$0.00Periodontal hygiene instruction

$0.00Gingival irrigation - Per quadrantD4921

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

$575.00Full upper dentureD5110

$575.00Full lower dentureD5120

$590.00Immediate full upper dentureD5130

$590.00Immediate full lower dentureD5140

$430.00Upper partial denture – Resin base (including retentive/clasping materials, rests, and teeth)

D5211

$430.00Lower partial denture – Resin base (including retentive/clasping materials, rests, and teeth)

D5212

$670.00Upper partial denture – Cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)

D5213

$670.00Lower partial denture – Cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)

D5214

$430.00Immediate upper partial denture – Resin base (including retentive/clasping materials, rests and teeth)

D5221

$430.00Immediate lower partial denture – Resin base (including retentive/clasping materials, rests and teeth)

D5222

$670.00Immediate upper partial denture – Cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)

D5223

$670.00Immediate lower partial denture – Cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)

D5224

CIGNA DENTAL CARE PLAN

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$460.00Upper partial denture – Flexible base (including retentive/ clasping materials, rests and teeth)

D5225

$460.00Lower partial denture – Flexible base (including retentive/ clasping materials, rests and teeth)

D5226

$430.00Immediate upper partial denture - Flexible base (including any clasps, rests and teeth)

D5227

$430.00Immediate lower partial denture - Flexible base (including any clasps, rests and teeth)

D5228

$38.00Adjust complete denture – UpperD5410

$38.00Adjust complete denture – LowerD5411

$38.00Adjust partial denture – UpperD5421

$38.00Adjust partial denture – LowerD5422

Repairs to prosthetics

$73.00Repair broken complete denture base - LowerD5511

$73.00Repair broken complete denture base - UpperD5512

$73.00Replace missing or broken teeth – Complete denture (each tooth)

D5520

$73.00Repair resin partial denture base - LowerD5611

$73.00Repair resin partial denture base - UpperD5612

$92.00Repair or replace broken retentive/clasping materials - Per toothD5630

$73.00Replace broken teeth – Per toothD5640

$73.00Add tooth to existing partial dentureD5650

$92.00Add clasp to existing partial denture - Per toothD5660

Denture relining (limit 1 every 24 months)

$220.00Rebase complete upper dentureD5710

$220.00Rebase complete lower dentureD5711

$220.00Rebase upper partial dentureD5720

CIGNA DENTAL CARE PLAN

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$220.00Rebase lower partial dentureD5721

$440.00Rebase hybrid prosthesisD5725

$130.00Reline complete upper denture – DirectD5730

$130.00Reline complete lower denture – DirectD5731

$130.00Reline upper partial denture – DirectD5740

$130.00Reline lower partial denture – DirectD5741

$195.00Reline complete upper denture – IndirectD5750

$195.00Reline complete lower denture – IndirectD5751

$195.00Reline upper partial denture – IndirectD5760

$195.00Reline lower partial denture – IndirectD5761

$195.00Soft liner for complete or partial removable denture – IndirectD5765

Interim dentures (limit 1 every 5 years)

$330.00Interim complete denture – UpperD5810

$330.00Interim complete denture – LowerD5811

$265.00Interim partial denture (including retentive/clasping materials, rests and teeth), upper

D5820

$265.00Interim partial denture (including retentive/clasping materials, rests and teeth), lower

D5821

$230.00Modification of removable prosthesis following implant surgeryD5875

$220.00Add metal substructure to acrylic full denture (per arch)D5876

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.

$150.00Additional charge per tooth/unit for crowns, inlays, onlays, post and cores, and veneers if your dentist uses same day in-office CAD/CAM (ceramic) services. Same day in-office CAD/CAM (ceramic) services refer to dental restorations that are created in

CIGNA DENTAL CARE PLAN

92251.b - 17 -the dental office by the use of a digital impression and an in-office CAD/CAM milling machine.

$815.00Abutment supported porcelain/ceramic crownD6058

$770.00Abutment supported porcelain fused to metal crown (high noble metal)

D6059

$715.00Abutment supported porcelain fused to metal crown (predominantly base metal)

D6060

$740.00Abutment supported porcelain fused to metal crown (noble metal)

D6061

$770.00Abutment supported cast metal crown (high noble metal)D6062

$715.00Abutment supported cast metal crown (predominantly base metal)

D6063

$740.00Abutment supported cast metal crown (noble metal)D6064

$815.00Implant supported porcelain/ceramic crownD6065

$770.00Implant supported crown - Porcelain fused to high noble alloysD6066

$770.00Implant supported crown - High noble alloysD6067

$815.00Abutment supported retainer for porcelain/ceramic fixed partial denture

D6068

$770.00Abutment supported retainer for porcelain fused to metal fixed partial denture (high noble metal)

D6069

$715.00Abutment supported retainer for porcelain fused to metal fixed partial denture (predominantly base metal)

D6070

$740.00Abutment supported retainer for porcelain fused to metal fixed partial denture (noble metal)

D6071

$770.00Abutment supported retainer for cast metal fixed partial denture (high noble metal)

D6072

$715.00Abutment supported retainer for cast metal fixed partial denture (predominantly base metal)

D6073

$740.00Abutment supported retainer for cast metal fixed partial denture (noble metal)

D6074

CIGNA DENTAL CARE PLAN

92251.b - 18 -

$815.00Implant supported retainer for ceramic fixed partial dentureD6075

$770.00Implant supported retainer for fixed partial denture - Porcelain fused to high noble alloys

D6076

$770.00Implant supported retainer for metal fixed partial denture - High noble alloys

D6077

$715.00Implant supported crown – Porcelain fused to predominantly base alloys

D6082

$740.00Implant supported crown – Porcelain fused to noble alloysD6083

$770.00Implant supported crown – Porcelain fused to titanium and titanium alloys

D6084

$135.00Interim implant crownD6085

$715.00Implant supported crown – Predominantly base alloysD6086

$740.00Implant supported crown – Noble alloysD6087

$770.00Implant supported crown – Titanium and titanium alloysD6088

$82.00Re-cement implant/abutment supported crownD6092

$103.00Re-cement implant/abutment supported fixed partial dentureD6093

$770.00Abutment supported crown - Titanium and titanium alloysD6094

$82.00Remove broken implant retaining screwD6096

$770.00Abutment supported crown – Porcelain fused to titanium and titanium alloys

D6097

$715.00Implant supported retainer – Porcelain fused to predominantly base alloys

D6098

$740.00Implant supported retainer for fixed partial denture – Porcelain fused to noble alloys

D6099

$875.00Implant /abutment supported removable denture for edentulous arch – Upper

D6110

$875.00Implant /abutment supported removable denture for edentulous arch – Lower

D6111

CIGNA DENTAL CARE PLAN

92251.b - 19 -

$970.00Implant /abutment supported removable denture for partially edentulous arch – Upper

D6112

$970.00Implant /abutment supported removable denture for partially edentulous arch – Lower

D6113

$875.00Implant /abutment supported fixed denture for edentulous arch

– Upper

D6114

$875.00Implant /abutment supported fixed denture for edentulous arch

– Lower

D6115

$970.00Implant /abutment supported fixed denture for partially edentulous arch – Upper

D6116

$970.00Implant /abutment supported fixed denture for partially edentulous arch – Lower

D6117

$525.00Implant/abutment supported interim fixed denture for edentulous arch – Lower

D6118

$525.00Implant/abutment supported interim fixed denture for edentulous arch – Upper

D6119

$770.00Implant supported retainer – Porcelain fused to titanium and titanium alloys

D6120

$715.00Implant supported retainer for metal fixed partial denture – Predominantly base alloys

D6121

$740.00Implant supported retainer for metal fixed partial denture – Noble alloys

D6122

$770.00Implant supported retainer for metal fixed partial denture – Titanium and titanium alloys

D6123

$770.00Abutment supported retainer crown for fixed partial denture - Titanium and titanium alloys

D6194

$770.00Abutment supported retainer – Porcelain fused to titanium and titanium alloys

D6195

$0.00Remove interim implant componentD6198

$135.00Complex rehabilitation on implant/abutment supported prosthetic procedures – Additional charge per unit for multiple crown units/complex rehabilitation (6 or more units of crown and/

CIGNA DENTAL CARE PLAN

92251.b - 20 -or bridge in same treatment plan requires complex rehabilitation for each unit – ask your dentist for the guidelines)

Oral surgery (includes routine postoperative treatment) Surgical removal of impacted teeth are covered for ages below 15 when medically necessary.

$53.00Extraction of coronal remnants – Primary toothD7111

$53.00Extraction, erupted tooth or exposed root – Elevation and/or forceps removal

D7140

$115.00Extraction, erupted tooth – Removal of bone and/or section of tooth

D7210

$125.00Removal of impacted tooth – Soft tissueD7220

$165.00Removal of impacted tooth – Partially bonyD7230

$230.00Removal of impacted tooth – Completely bonyD7240

$245.00Removal of impacted tooth – Completely bony, unusual complications (narrative required)

D7241

$115.00Removal of residual tooth roots – Cutting procedureD7250

$165.00Coronectomy - Intentional partial tooth removalD7251

$355.00Oroantral fistula closureD7260

$330.00Primary closure of a sinus perforationD7261

$180.00Tooth stabilization of accidentally evulsed or displaced toothD7270

$210.00Exposure of an unerupted tooth (excluding wisdom teeth)D7280

$49.00Placement of device to facilitate eruption of impacted toothD7283

$180.00Incisional biopsy of oral tissue – Hard (bone, tooth) (tooth related

– not allowed when in conjunction with another surgical procedure)

D7285

$135.00Incisional biopsy of oral tissue – Soft (all others) (tooth related – not allowed when in conjunction with another surgical procedure)

D7286

$78.00Exfoliative cytological sample collectionD7287

$78.00Brush biopsy – Transepithelial sample collectionD7288

CIGNA DENTAL CARE PLAN

92251.b - 21 -

$115.00Alveoloplasty in conjunction with extractions – 4 or more teeth or tooth spaces per quadrant

D7310

$56.00Alveoloplasty in conjunction with extractions – 1 to 3 teeth or tooth spaces per quadrant

D7311

$155.00Alveoloplasty not in conjunction with extractions – 4 or more teeth or tooth spaces per quadrant

D7320

$74.00Alveoloplasty not in conjunction with extractions – 1 to 3 teeth or tooth spaces per quadrant

D7321

$195.00Removal of benign odontogenic cyst or tumor – Up to 1.25 cmD7450

$195.00Removal of benign odontogenic cyst or tumor – Greater than

1.25 cm

D7451

$215.00Removal of lateral exostosis – Maxilla or mandibleD7471

$215.00Removal of torus palatinusD7472

$215.00Removal of torus mandibularisD7473

$155.00Reduction of osseous tuberosityD7485

$74.00Incision and drainage of abscess – Intraoral soft tissueD7510

$115.00Incision and drainage of abscess – Intraoral soft tissue complicated

D7511

$455.00Occlusal orthotic device, by report - (limit 1 per 24 months; only covered in conjunction with Temporomandibular Joint (TMJ) treatment)

D7880

$38.00Occlusal orthotic device adjustmentD7881

$0.00Placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site

D7922

$14.00Buccal / labial frenectomy (frenulectomy)D7961

$20.00FrenuloplastyD7963

Orthodontics (tooth movement) - The Patient Charge for your entire orthodontic case, including retention, will be based upon the applicable charge in effect on the date your orthodontic treatment begins (banding/appliance insertion). Coverage is provided for

CIGNA DENTAL CARE PLAN

92251.b - 22 -twenty-four (24) months of active treatment. Cases beyond 24 months require an additional payment by the patient.

$480.00Limited orthodontic treatment of the primary dentition - BandingD8010

$480.00Limited orthodontic treatment of the transitional dentition – Banding

D8020

$230.00Limited orthodontic treatment of the adolescent dentition – Banding

D8030

$260.00Limited orthodontic treatment of the adult dentition – BandingD8040

$500.00Comprehensive orthodontic treatment of the transitional dentition – Banding

D8070

$515.00Comprehensive orthodontic treatment of the adolescent dentition – Banding

D8080

$515.00Comprehensive orthodontic treatment of the adult dentition – Banding

D8090

$66.00Pre-orthodontic treatment examination to monitor growth and development

D8660

Periodic orthodontic treatment visitD8670

Children - Up to 19th birthday:

$2,472.00 24-month treatment fee

$103.00Charge per month for 24 months

Adults:

$3,336.0024-month treatment fee

$139.00Charge per month for 24 months

$345.00Orthodontic retention – Removal of appliances, construction and placement of retainer(s)

D8680

$0.00Removable orthodontic retainer adjustmentD8681

$175.00Removal of fixed orthodontic appliances for reasons other than completion of treatment

D8695

CIGNA DENTAL CARE PLAN

92251.b - 23 -

$195.00Unspecified orthodontic procedure – By report (orthodontic treatment plan and records including all necessary images)

D8999

General anesthesia/IV sedation: coverage is provided when medically necessary for covered surgical procedures listed on the Patient Charge Schedule. Clinical guidelines related to the use of general anesthesia/IV sedation should be discussed with your treating network specialist.

$0.00Local anesthesiaD9215

$95.00Deep sedation/general anesthesia – First 15 minutesD9222

$95.00Deep sedation/general anesthesia – Each subsequent 15 minute increment

D9223

$60.00Inhalation of nitrous oxide / analgesia, anxiolysisD9230

$95.00Intravenous moderate (conscious) sedation/anesthesia – First 15 minutes

D9239

$95.00Intravenous moderate (conscious) sedation/analgesia - Each subsequent 15 minute increment

D9243

$50.00Infiltration of sustained release therapeutic drug, per quadrant (patient charge is per quadrant)

D9613

$15.00Application of desensitizing medicamentD9910

$0.00Application of desensitizing resin for cervical and/or root surface, per tooth

D9911

Emergency services

$48.00Palliative (emergency) treatment of dental pain – Minor procedure

D9110

$77.00Office visit – After regularly scheduled hoursD9440

Miscellaneous services

$0.00Pre-visit patient screeningD9912

$110.00Fabrication of athletic mouthguard (limit 1 per 12 months)D9941

$0.00Occlusal guard adjustmentD9943

$285.00Occlusal guard – Hard appliance, full arch (limit 1 per 24 months)D9944

CIGNA DENTAL CARE PLAN

92251.b - 24 -

$145.00Occlusal guard – Soft appliance, full arch (limit 1 per 24 months)D9945

$170.00Occlusal guard – Hard appliance, partial arch (limit 1 per 24 months)

D9946

$56.00Occlusal adjustment – LimitedD9951

$260.00Occlusal adjustment – CompleteD9952

$0.00Duplicate/copy patient's recordsD9961

$165.00External bleaching for home application, per arch; includes materials and fabrication of custom trays (all other methods of bleaching are not covered)

D9975

$0.00Certified translation or sign language services, per visitD9990

$0.00Teledentistry – Synchronous; real-time encounterD9995

$0.00Teledentistry – Asynchronous; information stored and forwarded to dentist for subsequent review

D9996

This may contain CDT Dental Procedure Codes and/or portions of, or excerpts from the Code on Dental Procedures and Nomenclature (CDT Code) contained within the current version of the “Dental Procedure Codes”, 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 PLAN

92251.b - 25 -

After your enrollment is effective:

Call the dental office identified in your Welcome Kit. If you wish to change dental offices, a transfer can be arranged at no charge by calling the toll free number listed on your ID card or plan materials. Multiple ways to locate a Network General Dentist:

› On-line provider directory at Cigna.com

› On-line provider directory on myCigna.com

› Call the number located on your ID card to:

– Use the Dental Office Locator via Speech Recognition

– Speak to a Customer Service Representative

EMERGENCY: If you have a dental emergency as defined in your group’s plan documents, contact your Network General Dentist as soon as possible.

If you are out of your service area or unable to contact your Network Office, emergency care can be rendered by any dental office, dental clinic, or other comparable facility. Definitive treatment (e.g., root canal) is not considered emergency care and should be performed or referred by your Network General Dentist. Consult your group’s plan documents for a complete definition of dental emergency, your emergency benefit and a listing of Exclusions and Limitations.

92251.b - 26 -

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“Cigna,” “Cigna Dental Care” and the “Tree of Life” logo 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 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. (Kentucky and Illinois); 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.

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92251.b © 2021 Cigna. Some content provided under license.