Attachment_11_-_2014_Dental_DHMO_Fee_Schedule.pdf

PDF 1 MB Posted Jun 24, 2014

Attached to: Dental Insurance Program Federal contract opportunity
Solicitation number: CC14HQR0010
Issued by: Department of the Treasury Office of the Comptroller of the Currency

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Attachment 9 - RFP Attachment 11 - DHMO Fee Schedule

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Other files attached to Dental Insurance Program, newest first.
File	Type	Posted
Dental_Insurance_RFP_Amendment_0001.pdf	PDF	Jun 24, 2014
Government_response_to_offeror_questions.pdf	PDF	Jun 24, 2014
Attachment_8_-_Dental_Insurance_Price_Proposal_Spreadsheet_(revised).xlsx	XLSX spreadsheet	Jun 24, 2014
CC14HQR0010_Amendment_0001 _Dental_Insurance _SF_30.pdf	PDF	Jun 24, 2014
Attachment_3_-_PWS_Exhibit_3_-_Claims_History_(Revised).xlsx	XLSX spreadsheet	Jun 24, 2014
Attachment_12_-_2014_Dental_DPPO_Coverage_Certificate.pdf	PDF	Jun 24, 2014
Attachment_1_-_PWS_Exhibit_1_-_Census_Data_(revised).xlsx	XLSX spreadsheet	Jun 24, 2014
Dental_Insurance_RFP_Amendment_0001_(with_track_changes).pdf	PDF	Jun 24, 2014
Attachment_10_-_2014_Dental_PPO_Summary.pdf	PDF	Jun 24, 2014
Attachment_8_-_Dental_Insurance_Price_Proposal_Spreadsheet.xlsx	XLSX spreadsheet	Jun 12, 2014
Attachment_9_-_Annual_NIST_800-53_Security_Self-Assessment.pdf	PDF	Jun 12, 2014
Attachment_2_-_PWS_Exhibit_2_-_PSR_Agreement.pdf	PDF	Jun 12, 2014
Attachment_6_-_Questions_Form.docx	DOCX document	Jun 12, 2014
Attachment_4_-_Non-Disclosure_Agreement.pdf	PDF	Jun 12, 2014
Dental_Insurance_RFP_CC14HQR0010.pdf	PDF	Jun 12, 2014
Attachment_5_-_IT_Accessibility_Questionnaire.pdf	PDF	Jun 12, 2014
Attachment_3_-_PWS_Exhibit_3_-_Claims_History.pdf	PDF	Jun 12, 2014
Attachment_7_-_Past_Performance_Questionnaires.pdf	PDF	Jun 12, 2014
Attachment_1_-_PWS_Exhibit_1_-_Census_Data.pdf	PDF	Jun 12, 2014

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F7-08

830565 10/11 F7-0892151

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

Important Highlights

Cigna Dental Care® (*DHMO) Patient Charge Schedule

•

This

Patient

Charge

Schedule

applies

only

when

covered

dental

services

are

performed

your

Network

Dentist,

unless

otherwise

authorized

Cigna

Dental

described

your

plan

documents.

Not

all

Network

Dentists

perform

all

listed

services

and

suggested

check

with

your

Network

Dentist

advance

receiving services.

•

This

Patient

Charge

Schedule

applies

Specialty

Care

when

appropriate

referral

made

Network

Specialty

Periodontist,

Orthodontist

Oral

Surgeon.

You

must

verify

with

the

Network

Specialty

Dentist

that

your

treatment

plan

has

been

authorized

for

payment

Cigna

Dental.

Prior

authorization

not

required

for

specialty

referrals

for

Pediatric

and

Endodontic

services.

You

may

select

Network

Pediatric

Dentist

for

your

child

under

the

age

calling

Customer

Service

1.800.Cigna24

get

list

Network

Pediatric

Dentists

your

area.

Coverage

for

treatment

Pediatric

Dentist

ends

your

child’s

7th

birthday;

however,

exceptions

for

medical

reasons

may

considered

individual

basis.

Your

Network

General

Dentist

will

provide

care

upon

your

child’s

7th

birthday.

•

Procedures

NOT

listed

this

Patient

Charge

Schedule

are

NOT

covered

and

are

the

patient’s

responsibility

the

dentist’s

usual

fees.

•

The

administration

sedation,

general

anesthesia,

and/or

Nitrous

Oxide

not

covered

except

specifically

listed

this

Patient

Charge

Schedule.

The

application

local

anesthetic

covered

part

your

dental

treatment.

•

Cigna

Dental

considers

infection

control

and/or

sterilization

incidental

and

part

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

the

Patient

Charge

Schedule

are

subject

the

plan

limitations

and

exclusions

described

your

plan

book/certificate

coverage

and/or

group

contract.

Attachment 11 - DHMO Fee Schedule

Cigna Dental Care® Patient Charge Schedule (F7-08)

-2-

Code Procedure Description Patient Charge

Diagnostic/Preventive –

Oral

evaluations

are

limited

combined

total

the

following

evaluations

during

consecutive

month

period:

Periodic

Oral

Evaluations

(D0120),

Comprehensive

Oral

Evaluations

(D0150),

Comprehensive

Periodontal

Evaluations

(D0180),

and

Oral

Evaluations

for

Patients

Under

Years

Age

(D0145).

D9310 Consultation	(Diagnostic	Service	Provided	by	Dentist	or
Physician	Other	than	Requesting	Dentist	or	Physician)

$0.00

D9430 Office Visit for Observation – No Other Services Performed $0.00

D9450 Case Presentation – Detailed and Extensive Treatment Planning

$0.00

D0120 Periodic Oral Evaluation – Established Patient $0.00

D0140 Limited Oral Evaluation – Problem Focused $0.00

D0145 Oral	Evaluation	for	a	Patient	Under	3	Years	of	Age	and
Counseling	with	Primary	Caregiver

$0.00

D0150 Comprehensive Oral Evaluation – New or Established Patient $0.00

D0170 Re-evaluation – Limited, Problem Focused (Not Postoperative Visit)

$0.00

D0210 X-Rays Intraoral – Complete Series (Including Bitewings) (Limit 1 Every 3 Years)

$0.00

D0220 X-Rays Intraoral – Periapical – First Film $0.00

D0230 X-Rays Intraoral – Periapical – Each Additional Film $0.00

D0240 X-Rays Intraoral – Occlusal Film $0.00

D0270 X-Rays (Bitewing) – Single Film $0.00

D0272 X-Rays (Bitewings) – 2 Films $0.00

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

•	The	American	Dental	Association	may	periodically	change	CDT	Codes	or	definitions.
Different	codes	may	be	used	to	describe	these	covered	procedures.

Important Highlights (continued)

-3-

Code Procedure Description Patient Charge

D0273 X-Rays (Bitewings) – 3 Films $0.00

D0274 X-Rays (Bitewings) – 4 Films $0.00

D0277 X-Rays (Bitewings, Vertical) – 7 to 8 Films $0.00

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

D0431 Oral Cancer Screening Using a Special Light Source $50.00

D0460 Pulp Vitality Tests $13.00

D0470 Diagnostic Casts $0.00

D0472 Pathology	Report	–	Gross	Examination	of	Lesion
(Only	When	Tooth	Related)

$0.00

D0473 Pathology	Report	–	Microscopic	Examination	of	Lesion
(Only	When	Tooth	Related)

$0.00

D0474 Pathology	Report	–	Microscopic	Examination	of	Lesion	and
Area	(Only	When	Tooth	Related)

$0.00

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

Additional	Prophylaxis	(Cleaning)	–	In	Addition	to	the
2	Prophylaxes	(Cleanings)	Allowed	per	Calendar	Year

$45.00

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

Additional	Prophylaxis	(Cleaning)	–	In	Addition	to	the
2	Prophylaxes	(Cleanings)	Allowed	per	Calendar	Year

$30.00

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

$0.00

D1206 Topical	Fluoride	Varnish	–	Therapeutic	Application	for
Moderate	to	High	Caries	Risk	Patients	–	Child	(Up to 19th

Birthday) (Limited to 2 per Calendar Year). There is a Combined Limit of a Total of 2 D1203s and/or D1206s per Calendar Year.

$0.00

D1330 Oral Hygiene Instructions $0.00

D1351 Sealant – Per Tooth $0.00

D1352 Preventive Resin Restoration in a Moderate to High Caries Risk Patient – Permanent Tooth

$0.00

D1510 Space Maintainer – Fixed – Unilateral $0.00

D1515 Space Maintainer – Fixed – Bilateral $0.00

D1555 Removal of Fixed Space Maintainer $0.00

-4-

Code Procedure Description Patient Charge

Restorative (Fillings)

D2140 Amalgam – 1 Surface, Primary or Permanent $0.00

D2150 Amalgam – 2 Surfaces, Primary or Permanent $0.00

D2160 Amalgam – 3 Surfaces, Primary or Permanent $0.00

D2161 Amalgam – 4 or More Surfaces, Primary or Permanent $0.00

D2330 Resin-Based Composite – 1 Surface, Anterior $0.00

D2331 Resin-Based Composite – 2 Surfaces, Anterior $0.00

D2332 Resin-Based Composite – 3 Surfaces, Anterior $0.00

D2335 Resin-Based	Composite	–	4	or	More	Surfaces	or	Involving
Incisal	Angle,	Anterior

$85.00

D2390 Resin-Based Composite Crown, Anterior $52.00

D2391 Resin-Based Composite – 1 Surface, Posterior $45.00

D2392 Resin-Based Composite – 2 Surfaces, Posterior $57.00

D2393 Resin-Based Composite – 3 Surfaces, Posterior $79.00

D2394 Resin-Based Composite – 4 or More Surfaces, Posterior $110.00

Crown and Bridge – All

charges

for

crown

and

bridge

(fixed

partial

denture)

are

per

unit

(each

replacement

supporting

tooth

equals

unit)

–

Replacement

limit

every

years.

D2510 Inlay – Metallic – 1 Surface $315.00

D2520 Inlay – Metallic – 2 Surfaces $315.00

D2530 Inlay – Metallic – 3 or More Surfaces $315.00

D2542 Onlay – Metallic – 2 Surfaces $360.00

D2543 Onlay – Metallic – 3 Surfaces $360.00

D2544 Onlay – Metallic – 4 or More Surfaces $360.00

D2740 Crown – Porcelain/Ceramic Substrate $380.00

D2750 Crown – Porcelain Fused to High Noble Metal $350.00

D2751 Crown – Porcelain Fused to Predominantly Base Metal $315.00

D2752 Crown – Porcelain Fused to Noble Metal $335.00

D2780 Crown – 3/4 Cast High Noble Metal $350.00

-5-

Code Procedure Description Patient Charge

D2781 Crown – 3/4 Cast Predominantly Base Metal $315.00

D2782 Crown – 3/4 Cast Noble Metal $335.00

D2790 Crown – Full Cast High Noble Metal $350.00

D2791 Crown – Full Cast Predominantly Base Metal $315.00

D2792 Crown – Full Cast Noble Metal $335.00

D2794 Crown – Titanium $350.00

D2910 Recement Inlay – Onlay or Partial Coverage Restoration $11.00

D2915 Recement Cast or Prefabricated Post and Core $11.00

D2920 Recement Crown $11.00

D2930 Prefabricated Stainless Steel Crown – Primary Tooth $11.00

D2931 Prefabricated Stainless Steel Crown – Permanent Tooth $11.00

D2932 Prefabricated Resin Crown $90.00

D2933 Prefabricated Stainless Steel Crown with Resin Window $95.00

D2934 Prefabricated	Esthetic	Coated	Stainless	Steel	Crown	–
Primary	Tooth

$95.00

D2940 Protective Restoration $12.00

D2950 Core Buildup – Including Any Pins $90.00

D2951 Pin Retention – Per Tooth – In Addition to Restoration $18.00

D2952 Post and Core – In Addition to Crown, Indirectly Fabricated $120.00

D2954 Prefabricated Post and Core – In Addition to Crown $95.00

D2960 Labial Veneer (Resin Laminate) – Chairside $105.00

D6210 Pontic – Cast High Noble Metal $350.00

D6211 Pontic – Cast Predominantly Base Metal $315.00

D6212 Pontic – Cast Noble Metal $335.00

D6214 Pontic – Titanium $350.00

D6240 Pontic – Porcelain Fused to High Noble Metal $350.00

D6241 Pontic – Porcelain Fused to Predominantly Base Metal $315.00

D6242 Pontic – Porcelain Fused to Noble Metal $335.00

D6245 Pontic – Porcelain/Ceramic $345.00

D6602 Inlay – Cast High Noble Metal, 2 Surfaces $350.00

-6-

Code Procedure Description Patient Charge

D6603 Inlay – Cast High Noble Metal, 3 or More Surfaces $350.00

D6604 Inlay – Cast Predominantly Base Metal, 2 Surfaces $315.00

D6605 Inlay – Cast Predominantly Base Metal, 3 or More Surfaces $315.00

D6606 Inlay – Cast Noble Metal, 2 Surfaces $325.00

D6607 Inlay – Cast Noble Metal, 3 or More Surfaces $335.00

D6610 Onlay – Cast High Noble Metal, 2 Surfaces $350.00

D6611 Onlay – Cast High Noble Metal, 3 or More Surfaces $350.00

D6612 Onlay – Cast Predominantly Base Metal, 2 Surfaces $315.00

D6613 Onlay – Cast Predominantly Base Metal, 3 or More Surfaces $305.00

D6614 Onlay – Cast Noble Metal, 2 Surfaces $335.00

D6615 Onlay – Cast Noble Metal, 3 or More Surfaces $335.00

D6624 Inlay – Titanium $350.00

D6634 Onlay – Titanium $350.00

D6740 Crown – Porcelain/Ceramic $380.00

D6750 Crown – Porcelain Fused to High Noble Metal $350.00

D6751 Crown – Porcelain Fused to Predominantly Base Metal $315.00

D6752 Crown – Porcelain Fused to Noble Metal $335.00

D6780 Crown – 3/4 Cast High Noble Metal $350.00

D6781 Crown – 3/4 Cast Predominantly Base Metal $315.00

D6782 Crown – 3/4 Cast Noble Metal $335.00

D6790 Crown – Full Cast High Noble Metal $350.00

D6791 Crown – Full Cast Predominantly Base Metal $315.00

D6792 Crown – Full Cast Noble Metal $335.00

D6794 Crown – Titanium $350.00

Complex	Rehabilitation	–	ADDITIONAL	CHARGE	PER	UNIT
FOR	MULTIPLE	CROWN	UNITS/COMPLEX	REHABILITATION

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

$135.00

D6930 Recement Fixed Partial Denture $11.00

-7-

Code Procedure Description Patient Charge

Implant Supported Prosthetics – All

charges

for

crown

and

bridge

(fixed

partial

denture)

are

per

unit

(each

replacement

supporting

implant(s)

equals

unit)

–

Replacement

limit

every

years.

All

charges

for

implant

supported

denture

are

limited

replacement

every

years.

D6053 Implant/Abutment	Supported	Removable	Denture	for
Completely	Edentulous	Arch

$760.00

D6054 Implant/Abutment	Supported	Removable	Denture	for
Partially	Edentulous	Arch

$830.00

D6058 Abutment Supported Porcelain/Ceramic Crown $680.00

D6059 Abutment	Supported	Porcelain	Fused	to	Metal	Crown	(High
Noble	Metal)

$650.00

D6060 Abutment	Supported	Porcelain	Fused	to	Metal	Crown
(Predominantly	Base	Metal)

$615.00

D6061 Abutment Supported Porcelain Fused to Metal Crown (Noble Metal)

$635.00

D6062 Abutment Supported Cast Metal Crown (High Noble Metal) $650.00

D6063 Abutment Supported Cast Metal Crown (Predominantly Base Metal)

$615.00

D6064 Abutment Supported Cast Metal Crown (Noble Metal) $635.00

D6065 Implant Supported Porcelain/Ceramic Crown $680.00

D6066 Implant	Supported	Porcelain	Fused	to	Metal	Crown	(Titanium,
Titanium	Alloy,	High	Noble	Metal)

$650.00

D6067 Implant	Supported	Metal	Crown	(Titanium,	Titanium	Alloy,
High	Noble	Metal)

$650.00

D6068 Abutment Supported Retainer for Porcelain/Ceramic Fixed Partial Denture

$680.00

D6069 Abutment	Supported	Retainer	for	Porcelain	Fused	to	Metal
Fixed	Partial	Denture	(High	Noble	Metal)

$650.00

D6070 Abutment	Supported	Retainer	for	Porcelain	Fused	to	Metal
Fixed	Partial	Denture	(Predominantly	Base	Metal)

$615.00

D6071 Abutment	Supported	Retainer	for	Porcelain	Fused	to	Metal
Fixed	Partial	Denture	(Noble	Metal)

$635.00

D6072 Abutment	Supported	Retainer	for	Cast	Metal	Fixed	Partial
Denture	(High	Noble	Metal)

$650.00

-8-

Code Procedure Description Patient Charge

D6073 Abutment	Supported	Retainer	for	Cast	Metal	Fixed	Partial
Denture	(Predominantly	Base	Metal)

$615.00

D6074 Abutment	Supported	Retainer	for	Cast	Metal	Fixed	Partial
Denture	(Noble	Metal)

$635.00

D6075 Implant Supported Retainer for Ceramic Fixed Partial Denture $680.00

D6076 Implant	Supported	Retainer	for	Porcelain	Fused	to	Metal
Fixed	Partial	Denture	(Titanium,	Titanium	Alloy,	High	Noble

Metal)

$650.00

D6077 Implant	Supported	Retainer	for	Cast	Metal	Fixed	Partial
Denture	(Titanium,	Titanium	Alloy,	High	Noble	Metal)

$650.00

D6078 Implant/	Abutment	Supported	Fixed	Denture	for	Completely
Edentulous	Arch

$760.00

D6079 Implant/Abutment	Supported	Fixed	Denture	for	Partially
Edentulous	Arch

$830.00

D6092 Recement Implant/Abutment Supported Crown $51.00

D6093 Recement Implant/Abutment Supported Fixed Partial Denture

$51.00

D6094 Abutment Supported Crown (Titanium) $650.00

D6194 Abutment Supported Retainer Crown for Fixed Partial Denture (Titanium)

$650.00

Complex	Rehabilitation	on	Implant	Supported	Prosthetic
Procedures	–	ADDITIONAL	CHARGE	PER	UNIT	FOR	MULTIPLE
CROWN	UNITS/COMPLEX	REHABILITATION	(6 or more units of

crown and/or bridge in same treatment plan requires complex rehabilitation for each unit – ask your dentist for the guidelines)

$135.00

Endodontics (Root Canal Treatment, Excluding Final Restorations)

D3110 Pulp Cap – Direct (Excluding Final Restoration) $13.00

D3120 Pulp Cap – Indirect (Excluding Final Restoration) $13.00

D3220 Pulpotomy – Removal of Pulp, Not Part of a Root Canal $19.00

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

$19.00

D3222 Partial	Pulpotomy	for	Apexogenesis	–	Permanent	Tooth	with
Incomplete	Root	Development

$19.00

-9-

Code Procedure Description Patient Charge

D3310 Anterior Root Canal – Permanent Tooth (Excluding Final Restoration)

$12.00

D3320 Bicuspid Root Canal – Permanent Tooth (Excluding Final Restoration)

$31.00

D3330 Molar Root Canal – Permanent Tooth (Excluding Final Restoration)

$245.00

D3331 Treatment of Root Canal Obstruction – Nonsurgical Access $13.00

D3332 Incomplete	Endodontic	Therapy	–	Inoperable,	Unrestorable
or	Fractured	Tooth

$13.00

D3333 Internal Root Repair of Perforation Defects $13.00

D3346 Retreatment of Previous Root Canal Therapy – Anterior $13.00

D3347 Retreatment of Previous Root Canal Therapy – Bicuspid $32.00

D3348 Retreatment of Previous Root Canal Therapy – Molar $310.00

D3410 Apicoectomy/Periradicular Surgery – Anterior $13.00

D3421 Apicoectomy/Periradicular Surgery – Bicuspid (First Root) $43.00

D3425 Apicoectomy/Periradicular Surgery – Molar (First Root) $74.00

D3426 Apicoectomy/Periradicular Surgery (Each Additional Root) $13.00

D3430 Retrograde Filling per Root $13.00

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,

applicable),

when

covered

the

Patient

Charge

Schedule.

The

Relevant

Procedure

Codes

are

D4263,

D4264,

D4266

and

D4267.

Localized

delivery

antimicrobial

agents

limited

Teeth

(or

sites,

applicable)

per

consecutive

months,

when

covered

the

Patient

Charge

Schedule.

D0180 Comprehensive Periodontal Evaluation – New or Established Patient

$32.00

D4210 Gingivectomy or Gingivoplasty – 4 or More Teeth per Quadrant $180.00

D4211 Gingivectomy or Gingivoplasty – 1 to 3 Teeth per Quadrant $93.00

D4240 Gingival	Flap	(Including	Root	Planing)	–	4	or	More	Teeth
per	Quadrant

$230.00

D4241 Gingival	Flap	(Including	Root	Planing)	–	1	to	3	Teeth
per	Quadrant

$120.00

D4245 Apically Positioned Flap $230.00

-10-

Code Procedure Description Patient Charge

D4249 Clinical Crown Lengthening – Hard Tissue $250.00

D4260 Osseous Surgery – 4 or More Teeth per Quadrant $415.00

D4261 Osseous Surgery – 1 to 3 Teeth per Quadrant $230.00

D4263 Bone Replacement Graft – First Site in Quadrant $290.00

D4264 Bone Replacement Graft – Each Additional Site in Quadrant $225.00

D4266 Guided Tissue Regeneration – Resorbable Barrier per Site $380.00

D4267 Guided	Tissue	Regeneration	–	Nonresorbable	Barrier	per	Site
(Includes	Membrane	Removal)

$430.00

D4270 Pedicle Soft Tissue Graft Procedure $305.00

D4271 Free Soft Tissue Graft Procedure (Including Donor Site Surgery)

$305.00

D4275 Soft Tissue Allograft $305.00

D4341 Periodontal	Scaling	and	Root	Planing	–	4	or	More	Teeth	per
Quadrant	(Limit 4 Quadrants per Consecutive 12 Months)

$83.00

D4342 Periodontal	Scaling	and	Root	Planing	–	1	to	3	Teeth	–	per
Quadrant	(Limit 4 Quadrants per Consecutive 12 Months)

$42.00

D4355 Full Mouth Debridement to Allow Evaluation and Diagnosis (1 per Lifetime)

$62.00

D4381 Localized Delivery of Antimicrobial Agents per Tooth – By Report

$45.00

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

$55.00

D9940 Occlusal Guard – By Report (Limit 1 per 24 Months) $195.00

D9951 Occlusal Adjustment Limited $43.00

D9952 Occlusal Adjustment Complete $200.00

Prosthetics

(Removable

Tooth

Replacement

–

Dentures)

Includes

adjustments

within

first

months

after

insertion

–

Replacement

limit

every

years.

D5110 Full Upper Denture $460.00

D5120 Full Lower Denture $460.00

D5130 Immediate Full Upper Denture $475.00

D5140 Immediate Full Lower Denture $475.00

-11-

Code Procedure Description Patient Charge

D5211 Upper	Partial	Denture	–	Resin	Base	(Including	Clasps,
Rests	and	Teeth)

$345.00

D5212 Lower	Partial	Denture	–	Resin	Base	(Including	Clasps,
Rests	and	Teeth)

$345.00

D5213 Upper	Partial	Denture	–	Cast	Metal	Famework	(Including
Clasps,	Rests	and	Teeth)

$530.00

D5214 Lower	Partial	Denture	–	Cast	Metal	Framework	(Including
Clasps,	Rests	and	Teeth)

$530.00

D5225 Upper	Partial	Denture	–	Flexible	Base	(Including	Clasps,
Rests	and	Teeth)

$355.00

D5226 Lower	Partial	Denture	–	Flexible	Base	(Including	Clasps,
Rests	and	Teeth)

$355.00

D5410 Adjust Complete Denture – Upper $31.00

D5411 Adjust Complete Denture – Lower $31.00

D5421 Adjust Partial Denture – Upper $31.00

D5422 Adjust Partial Denture – Lower $31.00

Repairs to Prosthetics

D5510 Repair Broken Complete Denture Base $55.00

D5520 Replace	Missing	or	Broken	Teeth	–	Complete	Denture
(Each	Tooth)

$55.00

D5610 Repair Resin Denture Base $55.00

D5630 Repair or Replace Broken Clasp $73.00

D5640 Replace Broken Teeth – Per Tooth $55.00

D5650 Add Tooth to Existing Partial Denture $55.00

D5660 Add Clasp to Existing Partial Denture $73.00

Denture Relining (Limit 1 Every 36 Months)

D5710 Rebase Complete Upper Denture $175.00

D5711 Rebase Complete Lower Denture $175.00

D5720 Rebase Upper Partial Denture $175.00

D5721 Rebase Lower Partial Denture $175.00

D5730 Reline Complete Upper Denture – Chairside $13.00

-12-

Code Procedure Description Patient Charge

D5731 Reline Complete Lower Denture – Chairside $13.00

D5740 Reline Upper Partial Denture – Chairside $13.00

D5741 Reline Lower Partial Denture – Chairside $13.00

D5750 Reline Complete Upper Denture – Laboratory $145.00

D5751 Reline Complete Lower Denture – Laboratory $145.00

D5760 Reline Upper Partial Denture – Laboratory $145.00

D5761 Reline Lower Partial Denture – Laboratory $145.00

Interim Dentures (Limit 1 Every 5 Years)

D5810 Interim Complete Denture – Upper $255.00

D5811 Interim Complete Denture – Lower $255.00

D5820 Interim Partial Denture – Upper $205.00

D5821 Interim Partial Denture – Lower $205.00

Oral Surgery (Includes

Routine

Postoperative

Treatment)

Surgical

Removal

Impacted

Tooth

–

Not

covered

for

ages

below

unless

pathology

(disease) exists.

D7111 Extraction of Coronal Remnants – Deciduous Tooth $12.00

D7140 Extraction,	Erupted	Tooth	or	Exposed	Root	–	Elevation
and/or	Forceps	Removal

$12.00

D7210 Surgical	Removal	of	Erupted	Tooth	–	Removal	of	Bone
and/or	Section	of	Tooth

$19.00

D7220 Removal of Impacted Tooth – Soft Tissue $19.00

D7230 Removal of Impacted Tooth – Partially Bony $62.00

D7240 Removal of Impacted Tooth – Completely Bony $115.00

D7241 Removal	of	Impacted	Tooth	–	Completely	Bony,	Unusual
Complications	(Narrative	Required)

$120.00

D7250 Surgical Removal of Residual Tooth Roots – Cutting Procedure $19.00

D7251 Coronectomy - Intentional Partial Tooth Removal $62.00

D7260 Oroantral Fistula Closure $120.00

D7261 Primary Closure of a Sinus Perforation $120.00

-13-

Code Procedure Description Patient Charge

D7270 Tooth Stabilization of Accidentally Evulsed or Displaced Tooth $13.00

D7280 Surgical Access of an Unerupted Tooth (Excluding Wisdom Teeth)

$13.00

D7283 Placement of Device to Facilitate Eruption of Impacted Tooth $7.00

D7285 Biopsy of Oral Tissue – Hard (Bone, Tooth) (Tooth Related – Not allowed when in conjunction with another surgical procedure)

$74.00

D7286 Biopsy of Oral Tissue – Soft (All Others) (Tooth Related – Not allowed when in conjunction with another surgical procedure)

$55.00

D7287 Exfoliative Cytological Sample Collection $74.00

D7288 Brush Biopsy – Transepithelial Sample Collection $74.00

D7310 Alveoloplasty	in	Conjunction	with	Extractions	–
4	or	More	Teeth	or	Tooth	Spaces	per	Quadrant

$13.00

D7311 Alveoloplasty	in	Conjunction	with	Extractions	–
1	to	3	Teeth	or	Tooth	Spaces	per	Quadrant

$7.00

D7320 Alveoloplasty	Not	in	Conjunction	with	Extractions	–
4	or	More	Teeth	or	Tooth	Spaces	per	Quadrant

$13.00

D7321 Alveoloplasty	Not	in	Conjunction	with	Extractions	–
1	to	3	Teeth	or	Tooth	Spaces	per	Quadrant

$7.00

D7450 Removal	of	Benign	Odontogenic	Cyst	or	Tumor	–
Up	to	1.25	cm

$13.00

D7451 Removal	of	Benign	Odontogenic	Cyst	or	Tumor	–
Greater	than	1.25	cm

$13.00

D7471 Removal of Lateral Exostosis – Maxilla or Mandible $13.00

D7472 Removal of Torus Palatinus $13.00

D7473 Removal of Torus Mandibularis $13.00

D7485 Surgical Reduction of Osseous Tuberosity $13.00

D7510 Incision and Drainage of Abscess – Intraoral Soft Tissue $13.00

D7511 Incision and Drainage of Abscess – Intraoral Soft Tissue Complicated

$19.00

D7960 Frenulectomy	–	Also	Known	as	Frenectomy	or	Frenotomy	–
Separate	Procedure	Not	Incidental	to	Another

$13.00

D7963 Frenuloplasty $19.00

-14-

Code Procedure Description Patient Charge

Orthodontics (Tooth	Movement)	Orthodontic	Treatment	(Maximum	benefit	of
24	months	of	interceptive	and/or	comprehensive	treatment.	Atypical	cases	or	cases
beyond	24	months	require	an	additional	payment	by	the	patient.)

D8050 Interceptive	Orthodontic	Treatment	of	the	Primary
Dentition	–	Banding

$480.00

D8060 Interceptive	Orthodontic	Treatment	of	the	Transitional
Dentition	–	Banding

$480.00

D8070 Comprehensive	Orthodontic	Treatment	of	the	Transitional
Dentition	–	Banding

$500.00

D8080 Comprehensive	Orthodontic	Treatment	of	the	Adolescent
Dentition	–	Banding

$515.00

D8090 Comprehensive	Orthodontic	Treatment	of	the	Adult
Dentition	–	Banding

$515.00

D8660 Pre-Orthodontic Treatment Visit $68.00

D8670 Periodic Orthodontic Treatment Visit – As Part of Contract

Children – Up to 19th Birthday:

24-Month Treatment Fee $1,560.00

Charge per Month for 24 Months $65.00

Adults:

24-Month Treatment Fee $2,300.00

Charge per Month for 24 Months $96.00

D8680 Orthodontic	Retention	–	Removal	of	Appliances,	Construction
and	Placement	of	Retainer(s)

$345.00

D8999 Unspecified Orthodontic Procedure – By Report (Orthodontic Treatment Plan and Records)

$195.00

-15-

Code Procedure Description Patient Charge

General Anesthesia/IV Sedation –

General

anesthesia

covered

when

performed

Oral

Surgeon

when

medically

necessary

for

covered

procedures

listed

the

Patient

Charge

Schedule.

sedation

covered

when

performed

Periodontist

Oral

Surgeon

when

medically

necessary

for

covered

procedures

listed

the

Patient

Charge Schedule. Plan limitation for this benefit is 1 hour per appointment. There is

coverage

for

general

anesthesia

intravenous

sedation

when

used

for

the

purpose

anxiety

control

patient

management.

D9220 General Anesthesia – First 30 Minutes $180.00

D9221 General Anesthesia – Each Additional 15 Minutes $80.00

D9241 IV Conscious Sedation – First 30 Minutes $180.00

D9242 IV Conscious Sedation – Each Additional 15 Minutes $73.00

Emergency Services

D9110 Palliative (Emergency) Treatment of Dental Pain – Minor Procedure

$0.00

D9440 Office Visit – After Regularly Scheduled Hours $65.00

Miscellaneous Services	–	External	Bleaching	(D9972)	is	limited	to	the	use	of
take-home	bleaching	trays.	All	other	bleaching	methods	are	not	covered.

D9972 External Bleaching per Arch $175.00

This

may

contain

CDT

codes

and/or

portions

of,

excerpts

from

the

Nomenclature

contained

within

the

Current Dental Terminology,

copyrighted

publication

provided

the

American

Dental

Association.

The

American

Dental

Association

does

not

endorse

any

codes

which

are

not

included

its

current

publication.

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

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

After

your

enrollment

effective:

Call

the

dental

office

identified

your

Welcome

Kit.

you

wish

change

dental

offices,

transfer

can

arranged

charge

calling

Cigna

Dental

the

toll-free

number

listed

your

card

plan

materials.

Multiple ways to locate a *DHMO Network General Dentist:

• Online provider directory at www.Cigna.com

• Online 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:

you

have

dental

emergency

defined

your

group’s

plan

documents,

contact

your

Network

General

Dentist

soon

possible.

you

are

out

your

service

area

unable

contact

your

Network

Office,

emergency

care

can

rendered

any

licensed

dentist.

Definitive

treatment

(e.g.,

root

canal)

not

considered

emergency

care

and

should

performed

referred

your

Network

General

Dentist.

Consult

your

group’s

plan

documents

for

complete

definition

dental

emergency,

your

emergency

benefit

and

listing

Exclusions

and

Limitations.

File details come from the government source that posted it. Updated Nov 14, 2017.