Download Patient Charge Schedule

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
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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)
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$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.
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