Download patient charge schedule

LC060
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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This Patient Charge Schedule applies only when covered dental services are
performed by your Network Dentist, unless otherwise authorized by CIGNA Dental
as described in your plan documents.
This Patient Charge Schedule applies to Specialty Care when an appropriate referral
is made to a Network Specialist (Endodontist, Periodontist, Orthodontist, Oral
Surgeon or Pediatric Dentist (up to 7th birthday unless medical reasons justify an
exception)). You must verify with the Network Specialist that your treatment plan has
been authorized for payment by CIGNA Dental.
Procedures NOT listed on this Patient Charge Schedule are NOT covered and are the
patient’s responsibility at the dentist’s usual fees.
The administration of I.V. sedation, general anesthesia, and/or nitrous oxide is not
covered except as specifically listed on this Patient Charge Schedule. The application
of local anesthetic is covered as part of your dental treatment.
This Patient Charge Schedule is subject to annual change in accordance with the
terms of the group agreement.
All patient charges must correspond to the Patient Charge Schedule in effect on the
date the procedure is initiated.
Connecticut General Life Insurance Company,
CIGNA HealthCare,
CIGNA Dental Health
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 Service
Organization licensed under Chapter 636 of the 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 New Mexico, Inc.
(Albuquerque and Santa Fe) ● 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. ● CIGNA Dental Health of Virginia, Inc.
90810
Cat. # 589291 03/03 LC060
CIGNA Dental Care
PATIENT CHARGE SCHEDULE (LC060)
Code‡
Patient Charge
Diagnostic/Preventive
D9310 Consultation (Diagnostic Service Provided By Dentist or
Physician Other Than Practitioner Providing Treatment)
D0120 Periodic Oral Evaluation
D0140 Limited Oral Evaluation – Problem Focused
D0150 Comprehensive Oral Evaluation
D0160 Detailed and Extensive Oral Evaluation – Problem Focused,
By Report
D0170 Re-evaluation – Limited, Problem Focused (Established
Patient; Not Post-Operative Visit)
D0210 X-Rays Intraoral – Complete Series (including bitewings) ★
D0220 X-Rays Intraoral – Periapical First Film
D0230 X-Rays Intraoral – Periapical Each Additional Film
D0240 X-Rays Intraoral – Occlusal Film
D0270 X-Rays (Bitewing) – Single Film
D0272 X-Rays (Bitewing) – Two Films
D0274 X-Rays (Bitewing) – Four Films
D0330 X-Rays (Panoramic) ★
D0460 Pulp Vitality Tests
D0470 Diagnostic Casts
D0501 Histopathologic Examinations
D1110 Prophylaxis – Adult ★★
D1120 Prophylaxis – Child ★★
D1201 Topical Application of Fluoride – (Including Prophylaxis) –
Child ◆ ★★
D1203 Topical Application of Fluoride – (Prophylaxis Not
Included) – Child ◆ ★★
D1330 Oral Hygiene Instructions
D1351 Sealant ■ ■ ✤
D1510 Space Maintainer – Fixed – Unilateral
D1515 Space Maintainer – Fixed – Bilateral
D1520 Space Maintainer – Removable – Unilateral
D1525 Space Maintainer – Removable – Bilateral
D1550 Recementation of Space Maintainer
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
$5.00
$15.00
$15.00
$15.00
$15.00
No Charge
Restorative (Fillings)
Amalgam – One Surface, Primary
Amalgam – Two Surfaces, Primary
Amalgam – Three Surfaces, Primary
Amalgam – Four or More Surfaces, Primary
Amalgam – One Surface, Permanent
Amalgam – Two Surfaces, Permanent
Amalgam – Three Surfaces, Permanent
Amalgam – Four or More Surfaces, Permanent
Resin-Based Composite – One Surface, Anterior
Resin-Based Composite – Two Surfaces, Anterior
Resin-Based Composite – Three Surfaces, Anterior
Resin-Based Composite – Four or More Surfaces or
Involving Incisal Angle (Anterior)
D2336 Resin-Based Composite Crown, Anterior – Primary
D2110
D2120
D2130
D2131
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
‡ Different Codes May Be Used to Describe These Covered Procedures
★★Limit 1 every 6 months
◆ Up to 19th birthday
■ ■ Per tooth
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
★ Limit 1 every 3 years
✤ Up to 14th birthday
CIGNA Dental Care
PATIENT CHARGE SCHEDULE (LC060)
Code‡
Patient Charge
D2380 Resin-Based Composite – One Surface, Posterior – Primary
D2381 Resin-Based Composite – Two Surfaces, Posterior – Primary
D2382 Resin-Based Composite – Three or More Surfaces,
Posterior – Primary
D2385 Resin-Based Composite – One Surface, Posterior –
Permanent
D2386 Resin-Based Composite – Two Surfaces, Posterior –
Permanent
D2387 Resin-Based Composite – Three Surfaces, Posterior –
Permanent
D2388 Resin-Based Composite – Four or More Surfaces,
Posterior – Permanent
$30.00
$40.00
$50.00
$30.00
$40.00
$60.00
$75.00
Crown and Bridge All charges for crown and bridge are per unit (each replacement or
supporting tooth equals one unit). Post and Core includes canal preparation. The
charges below include the cost of base or noble metal. High noble metal (precious), if
used, will be charged to the Member at an additional maximum amount of $100.00 per
tooth. If a cast post and core is made of high noble metal, an additional fee up to
$100.00 per tooth may be charged for the upgraded post and core. Porcelain and other
tooth-colored materials on molars is considered a material upgrade with a maximum
additional charge to the Member of $150.00.
D2510
D2520
D2530
D2542
D2543
D2544
D2710
D2720
D2721
D2722
D2740
D2750
D2751
D2752
D2780
D2781
D2782
D2790
D2791
D2792
D2910
D2920
D2930
D2931
D2932
D2933
D2940
D2950
D2951
D2952
Inlay – Metallic – One Surface
Inlay – Metallic – Two Surfaces
Inlay – Metallic – Three or More Surfaces
Onlay – Metallic – Two Surfaces
Onlay – Metallic – Three Surfaces
Onlay – Metallic – Four or More Surfaces
Crown – Resin (Laboratory)
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 Metal
Crown – 3/4 Cast Predominantly Base Metal
Crown – 3/4 Cast Noble Metal
Crown – Full Cast High Noble Metal
Crown – Full Cast Predominantly Base Metal
Crown – Full Cast Noble Metal
Recement Inlay
Recement Crown
Prefabricated Stainless Steel Crown – Primary Tooth
Prefabricated Stainless Steel Crown – Permanent Tooth
Prefabricated Resin Crown
Prefabricated Stainless Steel Crown with Resin Window
Sedative Filling
Core Buildup, Including Any Pins
Pin Retention ■ ■, In Addition to Restoration
Cast Post and Core, In Addition to Crown
‡ Different Codes May Be Used to Describe These Covered Procedures
■ ■ Per tooth
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
$40.00
$60.00
$60.00
$60.00
$60.00
$60.00
$60.00
$60.00
$60.00
$60.00
$60.00
$60.00
$60.00
$60.00
No Charge
No Charge
No Charge
No Charge
$10.00
$10.00
$10.00
$35.00
$10.00
$10.00
CIGNA Dental Care
PATIENT CHARGE SCHEDULE (LC060)
Code‡
D2953 Each Additional Cast Post – Same Tooth
D2954 Prefabricated Post and Core In Addition to Crown (Base
Metal Post)
D2957 Each Additional Prefabricated Post – Same Tooth (Base
Metal Post)
D2970 Temporary Crown – Fractured Tooth
D2980 Crown Repair
D6210 Pontic – Cast High Noble Metal
D6211 Pontic – Cast Predominantly Base Metal
D6212 Pontic – Cast Noble Metal
D6240 Pontic – Porcelain Fused to High Noble Metal
D6241 Pontic – Porcelain Fused to Predominantly Base Metal
D6242 Pontic – Porcelain Fused to Noble Metal
D6250 Pontic – Resin with High Noble Metal
D6251 Pontic – Resin with Predominantly Base Metal
D6252 Pontic – Resin with Noble Metal
D6520 Inlay – Metallic – Two Surfaces
D6530 Inlay – Metallic – Three or More Surfaces
D6543 Onlay – Metallic – Three Surfaces
D6544 Onlay – Metallic – Four or More Surfaces
D6720 Crown – Resin with High Noble Metal
D6721 Crown – Resin with Predominantly Base Metal
D6722 Crown – Resin with Noble Metal
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
D6790 Crown – Full Cast High Noble Metal
D6791 Crown – Full Cast Predominantly Base Metal
D6792 Crown – Full Cast Noble Metal
D6930 Recement Fixed Partial Denture
D6940 Stress Breaker
D6970 Cast Post and Core, In Addition to Fixed Partial Denture
Retainer
D6971 Cast Post as Part of Fixed Partial Denture Retainer
D6972 Prefabricated Post and Core In Addition to Fixed Partial
Denture Retainer – Base Metal Post
D6973 Core Buildup for Retainer, Including Any Pins
D6976 Each Additional Cast Post – Same Tooth
D6977 Each Additional Prefabricated Post – Same Tooth
D6980 Fixed Partial Denture Repair
Patient Charge
$10.00
$35.00
$10.00
$10.00
$10.00
$60.00
$60.00
$60.00
$60.00
$60.00
$60.00
$60.00
$60.00
$60.00
No Charge
No Charge
No Charge
No Charge
$60.00
$60.00
$60.00
$60.00
$60.00
$60.00
$60.00
$60.00
$60.00
$60.00
$60.00
$60.00
No Charge
No Charge
$10.00
$10.00
$10.00
$10.00
$10.00
$10.00
$15.00
Endodontics (Root canal treatment, excluding final restorations)
No Charge
D3110 Pulp Cap – Direct (Excluding Final Restoration)
No Charge
D3120 Pulp Cap – Indirect (Excluding Final Restoration)
D3220 Therapeutic Pulpotomy (Excluding Final Restoration) –
Removal of Pulp Coronal to the Dentinocemental Junction and
No Charge
Application of Medicament
D3221 Gross Pulpal Debridement, Primary and Permanent Teeth (Not
$6.00
to be Used by Provider Completing Endodontic Treatment)
‡ Different Codes May Be Used to Describe These Covered Procedures
CIGNA Dental Care
PATIENT CHARGE SCHEDULE (LC060)
Code‡
Patient Charge
D3230 Pulpal Therapy (Resorbable Filling) – Anterior, Primary Tooth
(Excluding Final Restoration)
$6.00
D3240 Pulpal Therapy (Resorbable Filling) – Posterior, Primary Tooth
(Excluding Final Restoration)
$6.00
D3310 Anterior Root Canal (Excluding Final Restoration)
$30.00
D3320 Bicuspid Root Canal (Excluding Final Restoration)
$60.00
D3330 Molar Root Canal (Excluding Final Restoration)
$90.00
D3346 Retreatment of Previous Root Canal Therapy – Anterior
$45.00
D3347 Retreatment of Previous Root Canal Therapy – Bicuspid
$75.00
D3348 Retreatment of Previous Root Canal Therapy – Molar
$105.00
D3410 Apicoectomy/Periradicular Surgery – Anterior
$50.00
D3421 Apicoectomy/Periradicular Surgery – Bicuspid (First Root)
$50.00
D3425 Apicoectomy/Periradicular Surgery – Molar (First Root)
$50.00
D3426 Apicoectomy/Periradicular Surgery (Each Additional Root)
No Charge
D3430 Retrograde Filling – Per Root
$50.00
D3450 Root Amputation – Per Root (Not Covered in Conjunction with
No Charge
Procedure D3920)
Periodontics (Includes post-operative evaluations and treatment under a local
anesthetic)
Gingivectomy or Gingivoplasty – Per Quadrant
$75.00
Gingivectomy or Gingivoplasty – Per Tooth (fewer than 6 teeth)
$15.00
Gingival Curettage, Surgical – Per Quadrant
No Charge
Gingival Flap Procedure, Including Root Planing Per Quadrant
$75.00
Osseous Surgery – Including Flap Entry and Closure Per
Quadrant
$150.00
D4341 Periodontal Scaling and Root Planing Per Quadrant ✱
$15.00
D4355 Full Mouth Debridement to Enable Comprehensive Periodontal
Evaluation and Diagnosis ❂
$50.00
D4910 Periodontal Maintenance Procedure Following Active
Therapy ▲
No Charge
D4210
D4211
D4220
D4240
D4260
Prosthetics (Removable tooth replacement - dentures) (Includes up to 4 adjustments
within first 6 months after insertion) Characterization is considered an upgrade with a
maximum additional charge to the Member of $225.00 per denture.
D5110
D5120
D5130
D5140
D5211
D5212
D5213
D5214
D5410
D5411
D5421
D5422
Complete Denture – Maxillary
$75.00
Complete Denture – Mandibular
$75.00
Immediate Denture – Maxillary
$90.00
Immediate Denture – Mandibular
$90.00
Maxillary Partial Denture – Resin Base (Including Any
Conventional Clasps, Rests & Teeth)
$85.00
Mandibular Partial Denture – Resin Base (Including Any
Conventional Clasps, Rests & Teeth)
$85.00
Maxillary Partial Denture – Cast Metal Framework with Resin
Denture Bases (Including any Conventional Clasps, Rests & Teeth)
$85.00
Mandibular Partial Denture – Cast Metal Framework with Resin
Denture Bases (Including any Conventional Clasps, Rests & Teeth)
$85.00
Adjust Complete Denture – Maxillary
No Charge
Adjust Complete Denture – Mandibular
No Charge
Adjust Partial Denture – Maxillary
No Charge
Adjust Partial Denture – Mandibular
No Charge
‡ Different Codes May Be Used to Describe These Covered Procedures
✱ Limit 4 Quadrants Per Consecutive 12 Months
❂ 1 Per Lifetime
▲ Limit 2 Within 12 Months
CIGNA Dental Care
PATIENT CHARGE SCHEDULE (LC060)
Code‡
Patient Charge
Repairs to Prosthetics
D5510
D5520
D5610
D5620
D5630
D5640
D5650
D5660
Repair Broken Complete Denture Base
Replace Missing or Broken Teeth – Complete Denture (Each Tooth)
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
$15.00
$5.00
$15.00
$15.00
$15.00
$5.00
$5.00
$5.00
Denture Relining (Limit 1 every 36 months)
D5710
D5711
D5720
D5721
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
Rebase Complete Maxillary Denture
Rebase Complete Mandibular Denture
Rebase Maxillary Partial Denture
Rebase Mandibular Partial Denture
Reline Complete Maxillary Denture (Chairside)
Reline Complete Mandibular Denture (Chairside)
Reline Maxillary Partial Denture (Chairside)
Reline Mandibular Partial Denture (Chairside)
Reline Complete Maxillary Denture (Laboratory)
Reline Mandibular Complete Denture (Laboratory)
Reline Maxillary Partial Denture (Laboratory)
Reline Partial Mandibular Denture (Laboratory)
$30.00
$30.00
$30.00
$30.00
$15.00
$15.00
$15.00
$15.00
$30.00
$30.00
$30.00
$30.00
Interim Dentures (Limited to initial placement of interim partial denture/stayplate to
replace extracted anterior teeth during healing)
D5820
D5821
D5850
D5851
Interim Partial Denture (Maxillary)
Interim Partial Denture (Mandibular)
Tissue Conditioning, Maxillary
Tissue Conditioning, Mandibular
No Charge
No Charge
No Charge
No Charge
Oral Surgery (Includes post-operative evaluations and treatment under a local
anesthetic)
D7110
D7120
D7130
D7210
Extraction (Single Tooth)
Extraction (Each Additional Tooth)
Root Removal – Exposed Roots
Surgical Removal of Erupted Tooth Requiring Elevation of
Mucoperiosteal Flap and Removal of Bone and/or Section of
Tooth
No Charge
No Charge
No Charge
No Charge
Surgical removal of impacted tooth – (not covered unless pathology [disease]
exists). Surgical removal of wisdom tooth/3rd molar for orthodontic reasons
only is not covered.
D7220 Removal of Impacted Tooth – Soft Tissue
D7230 Removal of Impacted Tooth – Partial Bony
‡ Different Codes May Be Used to Describe These Covered Procedures
No Charge
$30.00
CIGNA Dental Care
PATIENT CHARGE SCHEDULE (LC060)
Code‡
Patient Charge
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)
D7286 Biopsy of Oral Tissue – Soft (All Others) ❀
D7310 Alveoplasty in Conjunction with Extractions Per Quadrant
D7320 Alveoplasty Not in Conjunction with Extractions Per Quadrant
D7471 Removal of Exostosis – Per Site
D7510 Incision and Drainage of Abscess – Intraoral Soft Tissue
D7960 Frenulectomy (Frenectomy or Frenotomy) – Separate Procedure
$40.00
$40.00
No Charge
No Charge
$30.00
$40.00
No Charge
No Charge
No Charge
Orthodontics (Tooth movement)
9999.8010 Orthodontic Evaluation
9999.8020 Orthodontic Treatment Plan and Records
9999.8025 Removable and/or Fixed Appliance(s) Insertion
for Interceptive Treatment
9999.8026 Fixed Appliance Insertion (Banding) for Comprehensive
Treatment
Orthodontic Treatment (maximum lifetime benefit of 24 months of interceptive
and/or comprehensive treatment) – can include:
9999.8360/
9999.8370/ Interceptive Orthodontic Treatment
9999.8460/
9999.8470/
9999.8480/ Class I, II, III Malocclusion – Comprehensive Treatment –
Combination of Primary and Permanent Teeth
9999.8560/
9999.8570/
9999.8580/ Class I, II, III Malocclusion – Comprehensive Treatment –
Permanent Teeth
Children (Up to 19th Birthday)
Adults
Atypical cases or cases beyond 24 months require an additional payment by
the patient.
9999.8750 Retention – Post Treatment Stabilization
(Includes Appliance(s) and Treatment)
$40.00
$150.00
$275.00
$300.00
$1,600.00
$1,800.00
$300.00
Adjunctive Services
D9211 Regional Block Anesthesia
D9212 Trigeminal Division Block Anesthesia
D9215 Local Anesthesia
‡ Different Codes May Be Used to Describe These Covered Procedures
❀Tooth Related - Not Allowed When in Conjunction with Another Surgical Procedure
No Charge
No Charge
No Charge
CIGNA Dental Care
PATIENT CHARGE SCHEDULE (LC060)
Code‡
Patient Charge
Emergency Services
D9110 Palliative (Emergency) Treatment of Dental Pain – Minor
Procedure
D9430 Office Visit for Observation (During Regularly Scheduled
Hours) – No Other Services Performed
D9440 Office Visit – After Regularly Scheduled Hours
$5.00
$5.00
$20.00
Office Visit Fee (Per patient, per office visit in addition to any other applicable patient
charges)
9999.9491 Office Visit Fee at Specialist’s Office
5.00
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 CIGNA Dental at 1.800.367.1037.
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 licensed dentist. 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.
All CDT Codes listed above are from Current Dental Terminology, 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.
Cat. # 589291
3/03
LC060
90810