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Download CIGNA DHMO Fee Schedule
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Cigna Dental Care® Patient Charge Schedule (G1-V8 TX) Code Patient Charge Procedure Description Oral Surgery (Includes Routine Postoperative Treatment) Surgical Removal of Impacted Tooth â Not covered for ages below 15 unless pathology (disease) exists. D7111 Extraction of Coronal Remnants â Deciduous Tooth $60.00 D7140 $64.00 $145.00 D7220 Extraction, Erupted Tooth or Exposed Root â Elevation and/or Forceps Removal Surgical Removal of Erupted Tooth â Removal of Bone and/or Section of Tooth Removal of Impacted Tooth â Soft Tissue D7230 Removal of Impacted Tooth â Partially Bony $225.00 D7240 Removal of Impacted Tooth â Completely Bony $300.00 D7241 $300.00 D7250 Removal of Impacted Tooth â Completely Bony, Unusual Complications (Narrative Required) Surgical Removal of Residual Tooth Roots â Cutting Procedure D7251 Coronectomy - Intentional Partial Tooth Removal $225.00 D7260 Oroantral Fistula Closure $450.00 D7261 Primary Closure of a Sinus Perforation $415.00 D7270 Tooth Stabilization of Accidentally Evulsed or Displaced Tooth $200.00 D7280 Surgical Access of an Unerupted Tooth (Excluding Wisdom Teeth) Placement of Device to Facilitate Eruption of Impacted Tooth $255.00 $215.00 D7287 Biopsy of Oral Tissue â Hard (Bone, Tooth) (Tooth Related â Not allowed when in conjunction with another surgical procedure) Biopsy of Oral Tissue â Soft (All Others) (Tooth Related â Not allowed when in conjunction with another surgical procedure) Exfoliative Cytological Sample Collection D7288 Brush Biopsy â Transepithelial Sample Collection $74.00 D7310 Alveoloplasty in Conjunction with Extractions â 4 or More Teeth or Tooth Spaces per Quadrant Alveoloplasty in Conjunction with Extractions â 1 to 3 Teeth or Tooth Spaces per Quadrant $120.00 D7210 D7283 D7285 D7286 D7311 -13- $155.00 $145.00 $65.00 $180.00 $74.00 $65.00
