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CODE PATIENT CHARGE SNJ10 New Jersey Public Employees' Health Benefit Programs Cigna Dental Care (*DHMO) Patient Charge Schedule This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. IMPORTANT HIGHLIGHTS • • • • • • • • Patients pay the Patient Charges listed below, only when these procedures are performed by a Network General Dentist. Procedures performed by a non-network dentist are not covered and patients pay the dentist's usual fees for those procedures. Procedures not listed on this Patient Charge Schedule are not covered and are the patient's responsibility at the dentist's usual fees. If more than one professionally accepted and appropriate method of treatment can be used to treat a dental condition, coverage will be limited to the less costly Covered Service. If you choose the more costly service, the fee listed on the Patient Charge Schedule will not apply. Discuss your options and increased financial obligations with your dentist. General anesthesia and I.V. sedation may be covered at the Patient Charge listed when required due to dental or medical necessity in conjunction with covered oral surgery procedures performed by a Network Specialist. This Patient Charge Schedule applies to Specialty Care when an appropriate referral is made to a Network Specialty Periodontist or Oral Surgeon. You must verify with the Network Specialty Dentist that your treatment plan has been authorized for payment by Cigna Dental. Prior authorization is not required for specialty referrals for Pediatric, Orthodontic and Endodontic services. You may select a Network Pediatric Dentist for your child under the age of 7 by calling Customer Service at 1.800.Cigna24 to get a list of Network Pediatric Dentists in your area. Coverage for treatment by a Pediatric Dentist ends on your child’s 7th birthday; however, exceptions for medical reasons may be considered on an individual basis. Your Network General Dentist will provide care upon your child’s 7th birthday. Cigna Dental considers infection control and/or sterilization to be incidental to and part of the charges for services provided and not separately chargeable. All Patient Charges correspond to the Patient Charge Schedule in effect on the date the procedure is initiated. Procedure codes listed are from the American Dental Association’s CDT 2015 Dental Procedure Codes ©. The American Dental Association may periodically change the Code on Dental Procedures and Nomenclature (CDT Code). Different codes may be used to describe these covered procedures. 92104c 1 CODE PATIENT CHARGE DIAGNOSTIC Clinical Oral Evaluation Oral evaluations are limited to two in a calendar year. Emergency or limited oral evaluations are covered, limited to one evaluation per patient, per dentist, per calendar year. There are no copayments for diagnostic services. D0120 Periodic oral evaluation – Established patient D0140 Limited oral evaluation – Problem focused D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver D0150 Comprehensive oral evaluation – New or established patient D0160 Detailed and extensive oral evaluation – Problem focused, by report Radiographs Bitewing radiographic images are limited to two series of up to 4 images in a calendar year; set of full mouth images (D0210) are limited to once per 36 month interval; no more than 18 films per set of full mouth images. D0210 Intraoral — Complete series of radiographic images D0220 Intraoral — Periapical first radiographic image D0230 Intraoral — Periapical each additional radiographic image D0240 Intraoral — Occlusal radiographic image D0250 Extraoral — First radiographic image D0260 Extraoral — Each additional radiographic image D0270 Bitewings — Single radiographic image D0272 Bitewings — Two radiographic images D0273 Bitewings — Three radiographic images D0274 Bitewings — Four radiographic images D0277 Vertical Bitewings — Seven to eight radiographic images D0290 Posterior — Anterior or lateral skull and facial bone survey radiographic image D0330 Panoramic radiographic image D0340 Cephalometric radiographic image D0391 Interpretation of diagnostic image by a practitioner not associated with the capture of the image, including report Tests and Laboratory Examinations D0415 Collection of microorganisms for culture and sensitivity D0416 Viral culture D0421 Genetic test for susceptibility to oral diseases D0425 Caries susceptibility tests D0460 Pulp vitality tests D0470 Diagnostic casts $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PREVENTIVE Dental Prophylaxis Limited to two in a Calendar Year D1110 Prophylaxis-Adult D1120 Prophylaxis-Child Topical Fluoride Treatment (Office Procedure) Limited to two in a Calendar Year, and only for eligible dependent children under the age of 19 years D1206 Topical application of fluoride varnish 92104c 2 $0.00 $0.00 $0.00 CODE PATIENT CHARGE D1208 Topical application of fluoride – Excluding varnish Other Preventive Services D1330 Oral hygiene instructions D1351 Sealant - Per tooth (Sealants are limited to once per lifetime for permanent molars of eligible dependent children under the age of 19 years) D1352 Preventive resin restoration in a moderate to high caries risk patient – Permanent tooth D1353 Sealant repair - Per tooth $0.00 $0.00 $0.00 Space Maintenance (Passive Appliances) D1510 Space maintainer-Fixed unilateral D1515 Space maintainer-Fixed bilateral D1520 Space maintainer-Removable unilateral D1525 Space maintainer-Removable bilateral D1550 Recement or re-bond space maintainer D1555 Removal of fixed space maintainer $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RESTORATIVE The replacement of a crown is covered only after a 5 year period measured from the date on which the crown was previously placed Amalgam Restoration (Including Polishing) D2140 Amalgam-One surface, primary or permanent D2150 Amalgam-Two surfaces, primary or permanent D2160 Amalgam-Three surfaces, primary or permanent D2161 Amalgam-Four or more surfaces, primary or permanent Resin-Based Composite Restorations - Direct D2330 Resin-based composite - One surface, anterior D2331 Resin-based composite - Two surfaces, anterior D2332 Resin-based composite – Three surfaces, anterior D2335 Resin-based composite - Four or more surfaces or involving Incisal angle (anterior) D2390 Resin-based composite Crown, anterior D2391 Resin-based composite –One surface, posterior D2392 Resin-based composite – Two surfaces, posterior D2393 Resin-based composite – Three surfaces, posterior D2394 Resin-based composite – Four or more surfaces, posterior Inlay/Onlay Restorations D2510 Inlay-metallic-One surface D2520 Inlay-metallic-Two surfaces D2530 Inlay-metallic-Three or more surfaces D2542 Onlay-metallic-Two surfaces D2543 Onlay-metallic-Three surfaces D2544 Onlay-metallic-Four or more surfaces D2610 Inlay-porcelain/ceramic-One surface D2620 Inlay-porcelain/ceramic-Two surfaces D2630 Inlay-porcelain/ceramic-Three or more surfaces D2642 Onlay-porcelain/ceramic-Two surfaces D2643 Onlay-porcelain/ceramic-Three surfaces D2644 Onlay-porcelain/ceramic-Four or more surfaces D2650 Inlay-resin-based composite-One surface 92104c 3 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.00 $15.00 $25.00 $35.00 $45.00 $100.00 $100.00 $100.00 $100.00 $100.00 $100.00 $115.00 $115.00 $115.00 $115.00 $115.00 $115.00 $115.00 CODE PATIENT CHARGE D2651 D2652 D2662 D2663 D2664 Inlay-resin-based composite-Two surfaces Inlay-resin-based composite-Three or more surfaces Onlay- resin-based composite-Two surfaces Onlay- resin-based composite-Three surfaces Onlay- resin-based composite-Four or more surfaces $115.00 $115.00 $115.00 $115.00 $115.00 Crowns D2710 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2780 D2781 D2790 D2791 D2792 D2794 – Single Restorations Only Crown-Resin-based composite (indirect) (See Note) Crown-Resin with high noble metal Crown-Resin with predominantly base metal Crown-Resin with noble metal Crown-Porcelain/ceramic substrate Crown-Porcelain fused to high noble metal Crown-Porcelain fused to predominantly base metal Crown-Porcelain fused to noble metal Crown-3/4 cast high noble netal Crown-3/4 cast predominantly base metal Crown-Full cast high noble metal Crown-Full cast predominantly base metal Crown-Full cast noble metal Crown – Titanium $115.00 $150.00 $150.00 $150.00 $200.00 $225.00 $200.00 $200.00 $225.00 $200.00 $225.00 $200.00 $200.00 $225.00 Other Restorative Services D2910 Recement or re-bond inlay, onlay, veneer or partial coverage restoration D2915 Recement or re-bond indirectly fabricated or prefabricated post and core D2920 Recement or re-bond crown D2921 Reattachment of tooth fragment, incisal edge or cusp D2929 Prefabricated porcelain/ceramic crown — Primary tooth D2930 Prefabricated stainless steel crown-Primary tooth D2931 Prefabricated stainless steel crown-Permanent tooth D2932 Prefabricated resin crown D2933 Prefabricated stainless steel crown with resin window D2934 Prefabricated esthetic coated stainless steel crown – Primary tooth D2940 Protective restoration D2941 Interim therapeutic restoration – Primary dentition D2950 Core buildup, including any pins when required D2951 Pin retention-Per tooth, in addition to restoration D2952 Post & core in addition to crown, indirectly fabricated D2954 Prefabricated post and core in addition to crown D2955 Post removal D2971 Additional procedures to construct new crown under existing partial denture framework D2980 Crown repair necessitated by restorative material failure D2981 Inlay repair necessitated by restorative material failure D2982 Onlay repair necessitated by restorative material failure D2983 Veneer repair necessitated by restorative material failure D2990 Resin infiltration of incipient smooth surface lesions Note: There is no patient charge for procedure D2710 when performed in conjunction with a permanent crown on the same tooth. ENDODONTICS 92104c 4 $0.00 $0.00 $0.00 $0.00 $49.00 $35.00 $35.00 $35.00 $35.00 $35.00 $0.00 $0.00 $0.00 $0.00 $40.00 $40.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CODE PATIENT CHARGE Pulp Capping D3110 Pulp cap-direct (excluding final restoration) D3120 Pulp cap-indirect (excluding final restoration) Pulpotomy D3220 Therapeutic pulpotomy (excluding final restoration) – Removal of pulp coronal to the dentinocemental junction and application of medicament D3222 Partial pulpotomy for apexogenesis - Permanent tooth with incomplete root development Endodontic Therapy on Primary Teeth D3230 Pulpal therapy (resorbable filling)-Anterior, primary tooth (excluding final restoration) D3240 Pulpal therapy (resorbable filling)-Posterior, primary tooth (excluding final restoration) $0.00 $0.00 $25.00 $25.00 $20.00 $20.00 Endodontic Therapy D3310 Endodontic therapy, anterior tooth (excluding final restoration) D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) D3330 Endodontic therapy, molar (excluding final restoration) $100.00 $125.00 $150.00 Endodontic Retreatment D3346 Retreatment of previous root canal therapy-Anterior D3347 Retreatment of previous root canal therapy-Bicuspid D3348 Retreatment of previous root canal therapy-Molar $125.00 $150.00 $175.00 Apexification/Recalcification D3351 Apexification/recalcification-Initial visit D3352 Apexification/recalcification-Interim medication replacement D3353 Apexification/recalcification-Final visit $35.00 $35.00 $35.00 Apicoectomy/Periapical Services D3410 Apicoectomy/periradicular surgery-Anterior D3421 Apicoectomy/periradicular surgery-Bicuspid (first root) D3425 Apicoectomy/periradicular surgery-Molar (first root) D3426 Apicoectomy/periradicular surgery-Each additional root D3427 Periradicular surgery without apicoectomy D3430 Retrograde filling-Per root D3450 Root amputation-Per root $90.00 $90.00 $90.00 $40.00 $90.00 $20.00 $40.00 Other Endodontic Procedures D3910 Surgical procedure for isolation of tooth with rubber dam D3920 Hemisection (including any root removal), not including root canal therapy $0.00 $60.00 PERIODONTICS Coverage for surgical periodontal procedures, excluding scaling and root planing, is limited to one surgical periodontal treatment per quadrant every 36 months; coverage for scaling and root planing is limited to one nonsurgical periodontal treatment per quadrant every 12 months Surgical Services (Including Usual Postoperative Care) D4210 Gingivectomy or gingivoplasty - Four or more contiguous teeth or tooth bounded spaces per quadrant 92104c 5 $85.00 CODE D4211 D4212 D4240 D4241 D4245 D4249 D4260 D4261 D4263 D4264 D4266 D4267 D4270 D4273 D4274 D4275 D4276 D4277 D4278 PATIENT CHARGE Gingivectomy or gingivoplasty - One to three contiguous teeth or tooth bounded spaces per quadrant Gingivectomy or gingivoplasty to allow access for restorative procedure — Per tooth Gingival flap procedure, including root planing- Four or more contiguous teeth or tooth bounded spaces per quadrant Gingival flap procedure, including root planing – One to three contiguous teeth or tooth bounded spaces per quadrant Apically positioned flap Clinical crown lengthening-Hard tissue Osseous surgery (Including elevation of a full thickness flap and closure) - Four or more contiguous teeth or tooth bounded spaces per quadrant Osseous surgery (including elevation of a full thickness flap and closure) - One to three contiguous teeth or tooth bounded spaces per quadrant Bone replacement graft-First site in quadrant Bone replacement graft-Each additional site in quadrant Guided tissue regeneration-Resorbable barrier per site Guided tissue regeneration-Nonresorbable barrier per site (Includes membrane removal) Pedicle soft tissue graft procedure Subepithelial connective tissue graft procedures, per tooth Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) Soft tissue allograft Combined connective tissue and double pedicle graft, per tooth Free soft tissue graft procedure (including donor site surgery) — First tooth or edentulous tooth position in a graft Free soft tissue graft procedure (including donor site surgery) — Each additional contiguous tooth or edentulous tooth position in same graft site $30.00 $12.00 $90.00 $60.00 $90.00 $90.00 $175.00 $100.00 $100.00 $50.00 $90.00 $90.00 $175.00 $175.00 $40.00 $175.00 $175.00 $70.00 $35.00 Non-Surgical Periodontal Services D4320 Provisional splinting-Intracoronal D4321 Provisional splinting-Extracoronal D4341 Periodontal scaling and root planing – Four or more teeth per quadrant D4342 Periodontal scaling and root planing – One to three teeth, per quadrant D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis $0.00 $0.00 $55.00 $40.00 $55.00 Other Periodontal Services D4910 Periodontal maintenance D4920 Unscheduled dressing change (by someone other than treating dentist or their staff) $30.00 $0.00 PROSTHODONTICS, REMOVABLE The replacement of an existing removable prosthetic appliance is covered only after a 5 year period measured from the date on which the appliance was previously placed Complete Dentures (Including Routine Post Delivery Care) D5110 Complete denture - Maxillary D5120 Complete denture – Mandibular D5130 Immediate denture – Maxillary D5140 Immediate denture – Mandibular Partial Dentures (Including Routine Post Delivery Care) 92104c 6 $250.00 $250.00 $275.00 $275.00 CODE D5211 D5212 D5213 D5214 D5225 D5226 D5281 PATIENT CHARGE Maxillary partial denture-Resin base (including any conventional clasps, rests and teeth) Mandibular partial denture-Resin base (including any conventional clasps, rests and teeth) Maxillary partial denture-Cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) Mandibular partial denture-Cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) Maxillary partial denture – Flexible base (including any clasps, rests and teeth) Mandibular partial denture – Flexible base (including any clasps, rests and teeth) Removable unilateral partial denture-one piece cast metal (including clasps and teeth) Adjustments to Dentures D5410 Adjust complete denture-Maxillary D5411 Adjust complete denture – Mandibular D5421 Adjust partial denture – Maxillary D5422 Adjust partial denture – Mandibular $250.00 $250.00 $275.00 $275.00 $300.00 $300.00 $125.00 $0.00 $0.00 $0.00 $0.00 Repairs to Complete Dentures D5510 Repair broken complete denture base D5520 Replace missing or broken teeth-complete denture-(each tooth) $35.00 $35.00 Repairs D5610 D5620 D5630 D5640 D5650 D5660 $35.00 $35.00 $35.00 $35.00 $35.00 $35.00 to Partial Dentures Repair resin denture base Repair cast framework Repair or replace broken clasp Replace broken teeth-Per tooth Add tooth to existing partial denture Add clasp to existing partial denture Denture Rebase Procedures D5710 Rebase complete maxillary denture D5711 Rebase complete mandibular denture D5720 Rebase maxillary partial denture D5721 Rebase mandibular partial denture $85.00 $85.00 $85.00 $85.00 Denture Reline Procedures D5730 Reline complete maxillary denture (chairside) D5731 Reline complete mandibular denture (chairside) D5740 Reline maxillary partial denture (chairside) D5741 Reline mandibular partial denture (chairside) D5750 Reline complete maxillary denture (laboratory) D5751 Reline complete mandibular denture (laboratory) D5760 Reline maxillary partial denture (laboratory) D5761 Reline mandibular partial denture (laboratory) $40.00 $40.00 $40.00 $40.00 $40.00 $40.00 $40.00 $40.00 Other D5810 D5811 D5820 D5821 $40.00 $40.00 $40.00 $40.00 Removable Prosthetic Services Interim complete denture (maxillary) Interim complete denture (mandibular) Interim partial denture (maxillary) Interim partial denture (mandibular) 92104c 7 CODE D5850 D5851 PATIENT CHARGE Tissue conditioning, (maxillary) Tissue conditioning, (mandibular) $40.00 $40.00 PROSTHODONTICS, FIXED Fixed Partial Denture Pontics D6210 Pontic-Cast high noble metal D6211 Pontic-Cast predominantly base metal D6212 Pontic-Cast noble metal D6214 Pontic – Titanium D6240 Pontic-Porcelain fused to high noble metal D6241 Pontic-Porcelain fused to predominantly base metal D6242 Pontic-Porcelain fused to noble metal D6245 Pontic-Porcelain/Ceramic D6250 Pontic-Resin with high noble metal D6251 Pontic-Resin with predominantly base metal D6252 Pontic-Resin with noble metal $225.00 $200.00 $200.00 $225.00 $225.00 $200.00 $200.00 $200.00 $150.00 $150.00 $150.00 Fixed Partial Denture Retainers-Inlays/Onlays D6545 Retainer-Cast metal for resin bonded fixed prosthesis D6549 Resin Retainer-for resin bonded fixed prosthesis D6602 Inlay - Cast high noble metal, two surfaces D6603 Inlay - Cast high noble metal, three or more surfaces D6604 Inlay - Cast predominantly base metal, two surfaces D6605 Inlay - Cast predominantly base metal, three or more surfaces D6606 Inlay - Cast noble metal, two surfaces D6607 Inlay - Cast noble metal, three or more surfaces D6610 Onlay - Cast high noble metal, two surfaces D6611 Onlay - Cast high noble metal, three or more surfaces D6612 Onlay - Cast predominantly base metal, two surfaces D6613 Onlay - Cast predominantly base metal, three or more surfaces D6614 Onlay - Cast noble metal, two surfaces D6615 Onlay - Cast noble metal, three or more surfaces D6624 Inlay – Titanium D6634 Onlay – Titanium $100.00 $75.00 $175.00 $175.00 $100.00 $100.00 $155.00 $155.00 $185.00 $185.00 $100.00 $100.00 $175.00 $175.00 $175.00 $185.00 Fixed Partial Denture Retainers-Crowns D6720 Crown-Resin with high noble metal D6721 Crown-Resin with predominantly base metal D6722 Crown-Resin with noble metal D6740 Crown-Porcelain/ceramic D6750 Crown-Porcelain Fused to high noble metal D6751 Crown-Porcelain Fused to predominantly base metal D6752 Crown-Porcelain fused to noble metal D6780 Crown-3/4 cast high noble metal D6781 Crown-3/4 cast predominantly base metal D6782 Crown-3/4 cast noble metal D6783 Crown-3/4 porcelain/ceramic D6790 Crown-Full cast high noble metal D6791 Crown-Full cast predominantly base metal D6792 Crown-Full cast noble metal $150.00 $150.00 $150.00 $200.00 $225.00 $200.00 $200.00 $225.00 $200.00 $200.00 $200.00 $225.00 $200.00 $200.00 92104c 8 CODE D6794 PATIENT CHARGE Crown – Titanium $225.00 Other Fixed Partial Denture Services D6930 Recement or re-bond fixed partial denture D6980 Fixed partial denture repair necessitated by restorative material failure $15.00 $25.00 ORAL AND MAXILLOFACIAL SURGERY Extractions (Includes Local Anesthesia, Suturing, If Needed, and Routine Post-Operative Care) D7111 Extraction, coronal remnants – Deciduous tooth $10.00 D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) $20.00 Surgical Extractions (Includes Local Anesthesia, Suturing, If Needed, and Routine Post-Operative Care) D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated D7220 Removal of impacted tooth-Soft tissue D7230 Removal of impacted tooth-Partially bony D7240 Removal of impacted tooth-Completely bony D7241 Removal of impacted tooth-Completely bony, with unusual surgical complications D7250 Surgical removal of residual tooth roots (cutting procedure) D7251 Coronectomy – Intentional partial tooth removal Other Surgical Procedures D7260 Oroantral fistula closure D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth D7280 Surgical access of an unerupted tooth D7282 Mobilization of erupted or malpositioned tooth to aid eruption D7283 Placement of device to facilitate eruption of impacted tooth D7285 Incisional biopsy of oral tissue-hard (bone, tooth) D7286 Incisional biopsy of oral tissue-Soft D7287 Exfoliative cytology sample collection D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report Alveoloplasty - Surgical Preparation of Ridge D7310 Alveoloplasty in conjunction with extractions – Four or more teeth or tooth spaces, per quadrant D7311 Alveoloplasty in conjunction with extractions – One to three teeth or tooth spaces, per quadrant D7320 Alveoloplasty not in conjunction with extractions - Four or more teeth or tooth spaces, per quadrant D7321 Alveoloplasty not in conjunction with extractions – One to three teeth or tooth spaces, per quadrant Surgical Excision of Intra-Osteous Lesions D7450 Removal of benign odontogenic cyst or tumor-Lesion diameter up to 1.25cm D7451 Removal of benign odontogenic cyst or tumor-Lesion diameter greater than 1.25cm D7460 Removal of benign nonodontogenic cyst or tumor-Lesion diameter up to 1.25cm D7461 Removal of benign nonodontogenic cyst or tumor-Lesion diameter greater than 1.25cm Excision of Bone Tissue 92104c 9 $30.00 $55.00 $55.00 $65.00 $65.00 $30.00 $33.00 $100.00 $60.00 $60.00 $60.00 $0.00 $60.00 $25.00 $13.00 $20.00 $30.00 $15.00 $35.00 $20.00 $60.00 $60.00 $60.00 $60.00 CODE D7471 D7472 D7473 D7485 PATIENT CHARGE Removal of lateral exostosis (maxilla or mandible) Removal of torus palatinus Removal of torus mandibularis Surgical reduction of osseous tuberosity Surgical Incision D7510 Incision and drainage of abscess-Intraoral soft tissue D7511 Incision and drainage of abscess – Intraoral soft tissue – Complicated (includes drainage of multiple fascial spaces) D7520 Incision and drainage of abscess-Extraoral soft tissue D7521 Incision and drainage of abscess – Extraoral soft tissue – Complicated (includes drainage of multiple fascial spaces) Other Repair Procedure D7953 Bone replacement graft for ridge preservation – Per site D7960 Frenulectomy - Also known as frenectomy or frenotomy - Separate procedure not incidental to another procedure D7963 Frenuloplasty D7970 Excision of hyperplastic tissue-Per arch D7971 Excision of pericoronal gingiva D7972 Surgical reduction of fibrous tuberosity Miscellaneous Services D9110 Palliative (emergency) treatment of dental pain-Minor procedure D9211 Regional block anesthesia D9212 Trigeminal division block anesthesia D9215 Local anesthesia in conjunction with operative or surgical procedures D9219 Evaluation for deep sedation or general anesthesia D9220 Deep sedation/general anesthesia-First 30 minutes D9221 Deep sedation/general anesthesia-Each additional 15 minutes D9230 Inhalation of nitrous oxide/analgesia, anxiolysis D9241 Intravenous moderate (conscious) sedation/analgesia – First 30 minutes D9242 Intravenous moderate (conscious) sedation/analgesia – Each additional 15 minutes D9310 Consultation - Diagnostic service provided by dentist or physician other than requesting dentist or physician D9430 Office visit for observation (during regularly scheduled hours) – No other services performed D9440 Office visit - After regularly scheduled hours D9610 Therapeutic parenteral drug, single administration D9612 Therapeutic parenteral drugs, two or more administrations, different medications D9630 Other drugs and/or medicaments, by report D9910 Application of desensitizing medicament D9930 Treatment of complications (post surgical) – Unusual circumstances, by report D9931 Cleaning and inspection of a removable appliance D9940 Occlusal guard, by report D9942 Repair and/or reline of occlusal guard D9951 Occlusal adjustment-Limited D9952 Occlusal adjustment-Complete ORTHODONTICS (Treatment Plan Maximum of 24 Months) (Standard Materials) 92104c 10 $90.00 $90.00 $90.00 $90.00 $25.00 $30.00 $35.00 $40.00 $75.00 $60.00 $65.00 $60.00 $30.00 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.00 $20.00 $0.00 $40.00 $20.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.00 $20.00 $0.00 $60.00 CODE PATIENT CHARGE 1. Patient under 18 years of age at the start of treatment - Class I, II and III malocclusion (patient charge required of $1,000 or 50% of reasonable and customary charges, whichever is less). 2. Patient 18 years of age or over at the start of treatment - Class I, II and III malocclusion (patient charge required of $1,750 or 50% of reasonable and customary charges, whichever is less). Includes Invisalign as an optional treatment procedure — this procedure may fall under the "More Expensive Services" option and as such, the member choosing this option would be responsible for the difference between Invisalign charges and the standard adult orthodontic charge *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. 92104c 11