ch-09 city of houston cigna dental care plan patient

CH-09 City of HoustonCIGNA DENTAL CARE® PLAN PATIENT CHARGE SCHEDULE

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

Important Highlights

› This Patient Charge Schedule applies only when covered dental servicesare performed by your Network Dentist, unless otherwise authorizedby Cigna Dental as described in your plan documents. Not all NetworkDentists perform all listed services and it is suggested to check withyour Network Dentist in advance of receiving services.

› This Patient Charge Schedule applies to Specialty Care when anappropriate referral is made by your Network General Dentist to aNetwork Specialty Endodontist, Periodontist or Oral Surgeon. A referralis not required for Specialty Care at a Network Specialty PediatricDentist or Orthodontist. You may select a Network Pediatric Dentistfor your child under the age of 13 by calling Customer Service at1.800.Cigna24 to get a list of Network Pediatric Dentists in your area.Coverage for treatment by a Pediatric Dentist ends on your child’s 13thbirthday; however, exceptions for medical reasons may be consideredon an individual basis. Your Network General Dentist will provide careupon your child’s 13th birthday.

› Procedures not listed on this Patient Charge Schedule are not coveredand are the patient’s responsibility at the dentist’s usual fees.

› The administration of IV sedation, general anesthesia, and/or nitrousoxide is not covered except as specifically listed on this Patient ChargeSchedule. The application of local anesthetic is covered as part of yourdental treatment.

› Cigna Dental considers infection control and/or sterilization to beincidental to and part of the charges for services provided and notseparately chargeable.

92438 Subject to Regulatory Approval

955499a 5/1/2022 CH-09

› This Patient Charge Schedule is subject to annual change in accordancewith the terms of the group agreement.

› Procedures listed on the Patient Charge Schedule are subject to the planlimitations and exclusions described in your plan book/certificate ofcoverage and/or group contract.

› All patient charges must correspond to the Patient Charge Schedule ineffect on the date the procedure is initiated.

› Current Dental Terminology ("CDT") codes are established by the AmericanDental Association (ADA) Council on Dental Benefit Programs inaccordance with authority granted by the federal government under theHealth Insurance and Portability and Accountability Act of 1996 (HIPAA)as the national terminology for reporting dental services, and arerecognized as the industry standard. The ADA publishes CDT as part of areference manual and may periodically change CDT Codes or definitions.Different codes may be used to describe these covered procedures. Thelanguage in italics is intended to clarify the members’ benefit.

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CIGNA DENTAL CAREPATIENT CHARGE SCHEDULE (CH-09)

Important Highlights (Continued)

PatientChargeProcedure DescriptionCode

Office visit fee – (per patient, per office visit in addition to any other applicable patientcharges)

$0.00Office visit fee

Diagnostic/preventive – Oral evaluations are limited to a combined total of 4 of thefollowing evaluations during a 12 consecutive month period: Periodic oral evaluations(D0120), comprehensive oral evaluations (D0150), comprehensive periodontal evaluations(D0180), and oral evaluations for patients under 3 years of age (D0145).

$0.00Consultation (diagnostic service provided by dentist or physicianother than requesting dentist or physician)

D9310

$0.00Consultation with a medical health care professionalD9311

$0.00Office visit for observation – No other services performedD9430

$0.00Case presentation – Detailed and extensive treatment planningD9450

$0.00Periodic oral evaluation – Established patientD0120

$0.00Limited oral evaluation – Problem focusedD0140

$0.00Oral evaluation for a patient under 3 years of age and counselingwith primary caregiver

D0145

$0.00Comprehensive oral evaluation – New or established patientD0150

$0.00Detailed and extensive oral evaluation - Problem focused, byreport (limit 2 per consecutive year; only covered in conjunctionwith Temporomandibular Joint (TMJ) evaluation)

D0160

$0.00Re-evaluation – Limited, problem focused (established patient;not post-operative visit)

D0170

$0.00Re-evaluation – Post-operative office visitD0171

$0.00Comprehensive periodontal evaluation – New or establishedpatient

D0180

$0.00Screening of a patientD0190

$0.00Assessment of a patientD0191


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$0.00X-rays intraoral – Complete series of radiographic images (limitedto 1 D0210 or D0709 every 3 years)

D0210

$0.00X-rays intraoral – Periapical – First radiographic imageD0220

$0.00X-rays intraoral – Periapical – Each additional radiographic imageD0230

$0.00X-rays intraoral – Occlusal radiographic imageD0240

$0.00X-rays extraoral – 2D projection radiographic image createdusing a stationary radiation source, and detector

D0250

$0.00X-rays extra-oral posterior dental radiographic image (limited to1 D0251 or D0705 per consecutive year)

D0251

$0.00X-rays (bitewing) – Single radiographic imageD0270

$0.00X-rays (bitewings) – 2 radiographic imagesD0272



$0.00X-rays (bitewings, vertical) – 7 to 8 radiographic imagesD0277

$0.00X-rays (panoramic radiographic image) – (limited to 1 D0330 orD0701 every 3 years) (when utilized for orthodontic services, seeD8999)

D0330

$0.002D cephalometric radiographic image - Acquisition,measurement and analysis

D0340

$0.002D oral/facial photographic images obtained intra-orally orextra-orally (when utilized for orthodontic services, see D8999)

D0350

$0.003D photographic image (when utilized for orthodontic services,see D8999)

D0351

$240.00Cone beam CT capture and interpretation for TMJ seriesincluding two or more exposures (limit 1 per consecutive year;

D0368

only covered in conjunction with Temporomandibular Joint (TMJ)evaluation)


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$0.00Interpretation of diagnostic image by a practitioner notassociated with capture of the image, including report (whenutilized for orthodontic services, see D8999)

D0391

$0.00Collection of microorganisms for culture and sensitivityD0415

$0.00Viral cultureD0416

$0.00Collection and preparation of saliva sample for laboratorydiagnostic testing

D0417

$0.00Analysis of saliva sampleD0418

$0.00Assessment of salivary flow by measurementD4019

$0.00Collection and preparation of genetic sample material forlaboratory analysis and report

D0422

$0.00Genetic test for susceptibility to diseases – Specimen analysisD0423

$0.00Caries susceptibility testsD0425

$0.00Oral cancer screening using a special light sourceD0431

$0.00Pulp vitality testsD0460

$0.00Diagnostic casts (when utilized for orthodontic services, see D8999)D0470

$0.00Pathology report – Gross examination of lesion (only when toothrelated)

D0472

$0.00Pathology report – Microscopic examination of lesion (only whentooth related)

D0473

$0.00Pathology report – Microscopic examination of lesion and area(only when tooth related)

D0474

$0.00Laboratory accession of brush biopsy sample, microscopicexamination, preparation and transmission of written report

D0486

$0.00Non-ionizing diagnostic procedure capable of quantifying,monitoring and recording changes in structure of enamel, dentinand cementum

D0600


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$0.00Caries risk assessment and documentation, with a finding of lowrisk

D0601

$0.00Caries risk assessment and documentation, with a finding ofmoderate risk

D0602

$0.00Caries risk assessment and documentation, with a finding of highrisk

D0603

$0.00X-rays (panoramic radiographic image) – Image capture only(limited to 1 D0330 or D0701 every 3 years) (when utilized fororthodontic services, see D8999)

D0701

$0.002D oral/facial photographic image obtained intra-orally orextra-orally – Image capture only

D0703

$0.003D photographic image – Image capture onlyD0704

$0.00X-rays extra-oral posterior dental radiographic image – Imagecapture only (limited to 1 D0251 or D0705 per consecutive year)

D0705

$0.00X-rays intraoral – Occlusal radiographic image – Image captureonly

D0706

$0.00X-rays intraoral – Periapical radiographic image – Image captureonly

D0707

$0.00X-rays intraoral – Bitewing radiographic image – Image captureonly

D0708

$0.00X-rays (intraoral – Complete series of radiographic images) –Image capture only (limit 1 D0210 or D0709 every 3 years)

D0709

$0.00Prophylaxis (cleaning) – Adult (limit 2 per consecutive year)D1110

$45.00Additional prophylaxis (cleaning) – In addition to the 2prophylaxes (cleanings) allowed per consecutive year

$0.00Prophylaxis (cleaning) – Child (limit 2 per consecutive year)D1120

$35.00Additional prophylaxis (cleaning) – In addition to the 2prophylaxes (cleanings) allowed per consecutive year


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$0.00Topical application of fluoride varnish (limit 2 per consecutiveyear). There is a combined limit of a total of 2 D1206s and/or D1208sper consecutive year.

D1206

$15.00Additional topical application of fluoride varnish in addition toany combination of two (2) D1206s (topical application of fluoridevarnish) and/or D1208s (topical application of fluoride - excludingvarnish) per consecutive year

$0.00Topical application of fluoride - Excluding varnish (limit 2 perconsecutive year) There is a combined limit of a total of 2 D1208sand/or D1206s per consecutive year.

D1208

$15.00Additional topical application of fluoride - Excluding varnish - Inaddition to any combination of two (2) D1206s (topicalapplications of fluoride varnish) and/or D1208s (topicalapplication of fluoride - excluding varnish) per consecutive year

$0.00Nutritional counseling for control of dental diseaseD1310

$0.00Tobacco counseling for the control and prevention of oraldisease

D1320

$0.00Counseling for the control and prevention of adverse oral,behavioral, and systemic health effects associated with high-risksubstance use

D1321

$0.00Oral hygiene instructionsD1330

$4.00Sealant – Per toothD1351

$4.00Preventive resin restoration in a moderate to high caries riskpatient – Permanent tooth

D1352

$4.00Sealant repair – Per toothD1353

$4.00Interim caries arresting medicament application - Per toothD1354

$0.00Caries preventive medicament application – Per toothD1355

$36.00Space maintainer – Fixed, Unilateral - Per quadrantD1510

$36.00Space maintainer – Fixed – Bilateral, UpperD1516

$36.00Space maintainer – Fixed – Bilateral, LowerD1517


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$36.00Space maintainer – Removable, Unilateral - Per quadrantD1520

$36.00Space maintainer – Removable – Bilateral, UpperD1526

$36.00Space maintainer – Removable – Bilateral, LowerD1527

$9.00Re-cement or re-bond bilateral space maintainer – UpperD1551

$9.00Re-cement or re-bond bilateral space maintainer – LowerD1552

$9.00Re-cement or re-bond unilateral space maintainer – Per quadrantD1553

$9.00Removal of fixed unilateral space maintainer – Per quadrantD1556

$9.00Removal of fixed bilateral space maintainer – UpperD1557

$9.00Removal of fixed bilateral space maintainer – LowerD1558

$36.00Distal shoe space maintainer – Fixed, Unilateral - Per quadrantD1575

Restorative (fillings - primary or permanent teeth, including polishing)

$8.00Amalgam – 1 surface, primary or permanentD2140

$10.00Amalgam – 2 surfaces, primary or permanentD2150

$12.00Amalgam – 3 surfaces, primary or permanentD2160

$12.00Amalgam – 4 or more surfaces, primary or permanentD2161

$8.00Resin-based composite – 1 surface, anteriorD2330

$10.00Resin-based composite – 2 surfaces, anteriorD2331

$12.00Resin-based composite – 3 surfaces, anteriorD2332

$48.00Resin-based composite – 4 or more surfaces or involving incisalangle, anterior

D2335

$20.00Resin-based composite crown, anteriorD2390

$32.00Resin-based composite – 1 surface, posteriorD2391

$48.00Resin-based composite – 2 surfaces, posteriorD2392

$64.00Resin-based composite – 3 surfaces, posteriorD2393


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$64.00Resin-based composite – 4 or more surfaces, posteriorD2394

Crown and bridge – All charges for crowns and bridges (fixed partial dentures) are perunit (each replacement or supporting tooth equals 1 unit). Coverage for replacement ofcrowns and bridges is limited to 1 every 5 years.For single crowns, retainer (“abutment”) crowns, and pontics: The charges below includethe cost of predominantly base metal alloy. You may be charged an additional amount,based on the type of material the dentist uses for your restoration. You may be charged:• No more than $300 per tooth for any noble metal alloys, high noble metal alloys, titaniumor titanium alloys

$215.00Inlay – Metallic – 1 surfaceD2510

$215.00Inlay – Metallic – 2 surfacesD2520

$215.00Inlay – Metallic – 3 or more surfacesD2530

$215.00Onlay – Metallic – 2 surfacesD2542

$215.00Onlay – Metallic – 3 surfacesD2543

$215.00Onlay – Metallic – 4 or more surfacesD2544

$210.00Inlay – Porcelain/ceramic, 1 surfaceD2610

$210.00Inlay – Porcelain/ceramic, 2 surfacesD2620

$210.00Inlay – Porcelain/ceramic, 3 or more surfacesD2630

$210.00Onlay – Porcelain/ceramic, 2 surfacesD2642

$210.00Onlay – Porcelain/ceramic, 3 surfacesD2643

$210.00Onlay – Porcelain/ceramic, 4 or more surfacesD2644

$215.00Inlay – Resin-based composite, 1 surfaceD2650

$215.00Inlay – Resin-based composite, 2 surfacesD2651

$215.00Inlay – Resin-based composite, 3 or more surfacesD2652

$215.00Onlay – Resin-based composite, 2 surfacesD2662

$215.00Onlay – Resin-based composite, 3 surfacesD2663

$215.00Onlay – Resin-based composite, 4 or more surfacesD2664


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$215.00Crown – Resin-based composite, indirectD2710

$215.00Crown – 3/4 resin-based composite, indirectD2712

$215.00Crown – Resin with high noble metalD2720

$215.00Crown – Resin with predominantly base metalD2721

$215.00Crown – Resin with noble metalD2722

$415.00Crown – Porcelain/ceramicD2740

$210.00Crown – Porcelain fused to high noble metalD2750

$210.00Crown – Porcelain fused to predominantly base metalD2751

$210.00Crown – Porcelain fused to noble metalD2752

$210.00Crown - Porcelain fused to titanium and titanium alloysD2753

$210.00Crown – 3/4 cast high noble metalD2780

$210.00Crown – 3/4 cast predominantly base metalD2781

$210.00Crown – 3/4 cast noble metalD2782

$210.00Crown – 3/4 porcelain/ceramicD2783

$210.00Crown – Full cast high noble metalD2790

$210.00Crown – Full cast predominantly base metalD2791

$210.00Crown – Full cast noble metalD2792

$210.00Crown – Titanium and titanium alloysD2794

$100.00Provisional crownD2799

$10.00Re-cement or re-bond inlay, onlay, veneer or partial coveragerestoration

D2910

$10.00Re-cement or re-bond indirectly fabricated or prefabricated postand core

D2915

$10.00Re-cement or re-bond crownD2920

$48.00Reattachment of tooth fragment, incisal edge or cuspD2921


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$105.00Prefabricated porcelain/ceramic crown – Permanent toothD2928

$105.00Prefabricated porcelain/ceramic crown - Primary toothD2929

$38.00Prefabricated stainless steel crown – Primary toothD2930

$38.00Prefabricated stainless steel crown – Permanent toothD2931

$35.00Prefabricated resin crownD2932

$35.00Prefabricated stainless steel crown with resin windowD2933

$38.00Prefabricated esthetic coated stainless steel crown – Primarytooth

D2934

$4.00Protective restorationD2940

$4.00Interim therapeutic restoration - Primary dentitionD2941

$20.00Restorative foundation for an indirect restorationD2949

$20.00Core buildup – Including any pinsD2950

$24.00Pin retention – Per tooth – In addition to restorationD2951

$40.00Post and core – In addition to crown, indirectly fabricatedD2952

$12.00Each additional indirectly prefabricated post – Same toothD2953

$40.00Prefabricated post and core – In addition to crownD2954

$12.00Post removal (not in conjunction with endodontic therapy)D2955

$10.00Each additional prefabricated post – Same toothD2957

$250.00Labial veneer (resin laminate) – DirectD2960

$50.00Additional procedures to construct new crown under existingpartial denture framework

D2971

$15.00Crown repair, necessitated by restorative material failureD2980

$15.00Veneer repair necessitated by restorative material failureD2983

$4.00Resin infiltration of incipient smooth surface lesionsD2990

$210.00Pontic – Cast high noble metalD6210


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$210.00Pontic – Cast predominantly base metalD6211

$210.00Pontic – Cast noble metalD6212

$210.00Pontic – Titanium and titanium alloysD6214

$210.00Pontic – Porcelain fused to high noble metalD6240

$210.00Pontic – Porcelain fused to predominantly base metalD6241

$210.00Pontic – Porcelain fused to noble metalD6242

$210.00Pontic – Porcelain fused to titanium and titanium alloysD6243

$210.00Pontic – Porcelain/ceramicD6245

$210.00Pontic – Resin with high noble metalD6250

$210.00Pontic – Resin with predominantly base metalD6251

$210.00Pontic – Resin with noble metalD6252

$185.00Provisional PonticD6253

$185.00Retainer – Cast metal for resin bonded fixed prosthesisD6545

$185.00Retainer inlay – Porcelain/ceramic, 2 surfacesD6600

$185.00Retainer inlay – Porcelain/ceramic, 3 or more surfacesD6601

$185.00Retainer inlay – Cast high noble metal, 2 surfacesD6602

$185.00Retainer inlay – Cast high noble metal, 3 or more surfacesD6603

$185.00Retainer inlay – Cast predominantly base metal, 2 surfacesD6604

$185.00Retainer inlay – Cast predominantly base metal, 3 or moresurfaces

D6605

$185.00Retainer inlay – Cast noble metal, 2 surfacesD6606

$185.00Retainer inlay – Cast noble metal, 3 or more surfacesD6607

$185.00Retainer onlay – Porcelain/ceramic, 2 surfacesD6608

$185.00Retainer onlay – Porcelain/ceramic, 3 or more surfacesD6609


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$185.00Retainer onlay – Cast high noble metal, 2 surfacesD6610

$185.00Retainer onlay – Cast high noble metal, 3 or more surfacesD6611

$185.00Retainer onlay – Cast predominantly base metal, 2 surfacesD6612

$185.00Retainer onlay – Cast predominantly base metal, 3 or moresurfaces

D6613

$185.00Retainer onlay – Cast noble metal, 2 surfacesD6614

$185.00Retainer onlay – Cast noble metal, 3 or more surfacesD6615

$185.00Retainer inlay – TitaniumD6624

$185.00Retainer onlay – TitaniumD6634

$185.00Retainer crown – Indirect resin based compositeD6710

$210.00Retainer crown – Resin with high noble metalD6720

$210.00Retainer crown – Resin with predominantly base metalD6721

$210.00Retainer crown – Resin with noble metalD6722

$415.00Retainer crown – Porcelain/ceramicD6740

$210.00Retainer crown – Porcelain fused to high noble metalD6750

$210.00Retainer crown – Porcelain fused to predominantly base metalD6751

$210.00Retainer crown – Porcelain fused to noble metalD6752

$210.00Retainer crown – Porcelain fused to titanium and titanium alloysD6753

$210.00Retainer crown – 3/4 cast high noble metalD6780

$210.00Retainer crown – 3/4 cast predominantly base metalD6781

$210.00Retainer crown – 3/4 cast noble metalD6782

$210.00Retainer crown – 3/4 porcelain/ceramicD6783

$210.00Retainer crown ¾ – Titanium and titanium alloysD6784

$210.00Retainer crown – Full cast high noble metalD6790


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$210.00Retainer crown – Full cast predominantly base metalD6791

$210.00Retainer crown – Full cast noble metalD6792

$210.00Retainer crown – Titanium and titanium alloysD6794

$0.00Re-cement or re-bond fixed partial dentureD6930

$32.00Stress breakerD6940

$75.00Precision attachmentD6950

$45.00Implant maintenance procedures, including removal ofprosthesis, cleansing of prosthesis and abutments and reinsertionof prosthesis

D6980

Endodontics (root canal treatment, excluding final restorations)

$12.00Pulp cap – Direct (excluding final restoration)D3110

$0.00Pulp cap – Indirect (excluding final restoration)D3120

$20.00Pulpotomy – Removal of pulp, not part of a root canalD3220

$0.00Pulpal debridement (not to be used when root canal is done onthe same day)

D3221

$17.00Partial pulpotomy for apexogenesis – Permanent tooth withincomplete root development

D3222

$20.00Pulpal therapy (resorbable filling) – Anterior, primary tooth(excluding final restoration)

D3230

$20.00Pulpal therapy (resorbable filling) – Posterior, primary tooth(excluding final restoration)

D3240

$95.00Anterior root canal – Permanent tooth (excluding finalrestoration)

D3310

$118.00Premolar root canal – Permanent tooth (excluding finalrestoration)

D3320

$162.00Molar root canal – Permanent tooth (excluding final restoration)D3330

$85.00Treatment of root canal obstruction – Nonsurgical accessD3331


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$70.00Incomplete endodontic therapy – Inoperable, unrestorable orfractured tooth

D3332

$85.00Internal root repair of perforation defectsD3333

$200.00Retreatment of previous root canal therapy – AnteriorD3346

$300.00Retreatment of previous root canal therapy – PremolarD3347

$450.00Retreatment of previous root canal therapy – MolarD3348

$0.00Apexification/recalcification – Initial visit (apical closure/calcificrepair of perforations, root resorption, etc.)

D3351

$0.00Apexification/recalcification – Interim medication replacement(apical closure/calcific repair of perforations, root resorption, etc.)

D3352

$0.00Apexification/recalcification – Final visit (includes completedroot canal therapy – Apical closure/calcific repair of perforations,root resorption, etc.)

D3353

$0.00Pulpal regeneration - initial visitD3355

$0.00Pulpal regeneration - interim medicationD3356

$0.00Pulpal regeneration - completion of treatmentD3357

$80.00Apicoectomy/periarticular surgery – AnteriorD3410

$80.00Apicoectomy/periradicular surgery –Premolar (first root)D3421

$80.00Apicoectomy/periradicular surgery – Molar (first root)D3425

$80.00Apicoectomy/periradicular surgery (each additional root)D3426

$20.00Retrograde filling per rootD3430

$95.00Root amputation – Per rootD3450

$990.00Endodontic endosseous implantD3460

$95.00Surgical repair of root resorption – AnteriorD3471

$95.00Surgical repair of root resorption – PremolarD3472

$95.00Surgical repair of root resorption – MolarD3473


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$95.00Surgical exposure of root surface without apicoectomy or repairof root resorption – Anterior

D3501

$95.00Surgical exposure of root surface without apicoectomy or repairof root resorption – Premolar

D3502

$95.00Surgical exposure of root surface without apicoectomy or repairof root resorption – Molar

D3503

$90.00Hemisection (including any root removal), not including rootcanal therapy

D3920

Periodontics (treatment of supporting tissues (gum and bone) of the teeth) - Periodontalregenerative procedures are limited to 1 regenerative procedure per site (or per tooth,if applicable), when covered on the Patient Charge Schedule. The relevant procedurecodes are D4263, D4264, D4265, D4266 and D4267. Localized delivery of antimicrobialagents is limited to 8 teeth (or 8 sites, if applicable) per 12 consecutive months, whencovered on the Patient Charge Schedule. The use of any tools or equipment, includingbut limited to handpieces, lasers, scalers, etc., is considered inclusive to the overall coveredprocedure listed on the Patient Charge Schedule, and cannot be separately charged.

$95.00Gingivectomy or gingivoplasty – 4 or more teeth per quadrantD4210

$64.00Gingivectomy or gingivoplasty – 1 to 3 teeth per quadrantD4211

$64.00Gingivectomy or gingivoplasty to allow access for restorativeprocedure, per tooth

D4212

$100.00Anatomical crown exposure - four or more contiguous teeth ortooth bounded spaces per quadrant

D4230

$100.00Anatomical crown exposure - one to three teeth or toothbounded spaces per quadrant

D4231

$125.00Gingival flap (including root planing) – 4 or more teeth perquadrant

D4240

$84.00Gingival flap (including root planing) – 1 to 3 teeth per quadrantD4241

$165.00Apically positioned flapD4245

$100.00Clinical crown lengthening – Hard tissueD4249

$140.00Osseous surgery – 4 or more teeth per quadrantD4260


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$94.00Osseous surgery – 1 to 3 teeth per quadrantD4261

$205.00Bone replacement graft – Retained natural tooth - First site inquadrant

D4263

$95.00Bone replacement graft – Retained natural tooth - Each additionalsite in quadrant

D4264

$95.00Biologic materials to aid in soft and osseous tissue regenerationD4265

$215.00Guided tissue regeneration – Resorbable barrier per siteD4266

$255.00Guided tissue regeneration – Nonresorbable barrier per site(includes membrane removal)

D4267

$245.00Pedicle soft tissue graft procedureD4270

$75.00Autogenous connective tissue graft procedure (including donorand recipient surgical sites) first tooth, implant or edentuloustooth position

D4273

$70.00Mesial/distal wedge procedure single tooth (when not performedin conjunction with surgical procedures in the same anatomicalarea)

D4274

$380.00Non-autogenous connective tissue graft (including recipientsite and donor material) first tooth, implant, or edentulous toothposition in graft

D4275

$245.00Free soft tissue graft procedure (including recipient and donorsurgical sites), first tooth, implant or edentulous (missing) toothposition in graft

D4277

$125.00Free soft tissue graft procedure (including recipient and donorsurgical sites), each additional contiguous tooth, implant oredentulous (missing) tooth position in same graft site

D4278

$38.00Autogenous connective tissue graft procedure (including donorand recipient surgical sites) – Each additional contiguous tooth,implant or edentulous tooth position in same graft site

D4283

$190.00Non-autogenous connective tissue graft procedure (includingrecipient surgical site and donor materials) – Each additional

D4285


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contiguous tooth, implant or edentulous tooth position in samegraft site

$20.00Provisional splinting - IntracoronalD4320

$20.00Provisional splinting - ExtracoronalD4321

$20.00Periodontal scaling and root planing – 4 or more teeth perquadrant (limited to once per quadrant per consecutive 12 months)

D4341

$14.00Periodontal scaling and root planing – 1 to 3 teeth per quadrant(limited to once per quadrant per consecutive 12 months)

D4342

$0.00Scaling in presence of generalized moderate or severe gingivalinflammation – Full mouth, after oral evaluation (limit 1 perconsecutive year)

D4346

$45.00Additional scaling in presence of generalized moderate or severegingival inflammation – Full mouth, after oral evaluation (limit 2per consecutive year)

$30.00Full mouth debridement to enable a comprehensive oralevaluation and diagnosis on a subsequent visit (1 treatment peryear)

D4355

$60.00Localized delivery of antimicrobial agents per toothD4381

$24.00Periodontal maintenance (limit 4 per consecutive year) (onlycovered after active periodontal therapy)

D4910

$55.00Additional periodontal maintenance procedures (beyond 4 perconsecutive year)

$0.00Periodontal charting for planning treatment of periodontaldisease

$0.00Periodontal hygiene instruction

$0.00Gingival Irrigation - Per quadrantD4921

Prosthetics (removable tooth replacement – dentures) - Includes up to 4 adjustmentswithin first 6 months after insertion – Replacement limit 1 every 5 years. Characterization


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is considered an upgrade with maximum additional charge to the member of $200.00per denture.

$260.00Full upper dentureD5110

$260.00Full lower dentureD5120

$270.00Immediate full upper dentureD5130

$270.00Immediate full lower dentureD5140

$260.00Upper partial denture – Resin base (including retentive/claspingmaterials, rests, and teeth)

D5211

$260.00Lower partial denture – Resin base (including retentive/claspingmaterials, rests, and teeth)

D5212

$270.00Upper partial denture – Cast metal framework with resin denturebases (including retentive/clasping materials, rests and teeth)

D5213

$270.00Lower partial denture – Cast metal framework with resin denturebases (including retentive/clasping materials, rests and teeth)

D5214

$260.00Immediate upper partial denture – Resin base (includingretentive/clasping materials, rests and teeth)

D5221

$260.00Immediate lower partial denture – Resin base (includingretentive/clasping materials, rests and teeth)

D5222

$270.00Immediate upper partial denture – Cast metal framework withresin denture bases (including retentive/clasping materials, restsand teeth

D5223

$270.00Immediate lower partial denture – Cast metal framework withresin denture bases (including retentive/clasping materials, restsand teeth)

D5224

$165.00Upper partial denture – Flexible base (including retentive/clasping materials, rests and teeth)

D5225

$165.00Lower partial denture – Flexible base (including retentive/clasping materials, rests and teeth)

D5226

$150.00Removable unilateral partial denture – One piece cast metal(including retentive/clasping materials, rests and teeth), upper

D5282


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$150.00D5283

$150.00D5284

$150.00D5286

$10.00D5410

$10.00D5411

$10.00D5421

$10.00

Removable unilateral partial denture – One piece cast metal (including retentive/clasping materials, rests and teeth), lower

Removable unilateral partial denture – One piece flexible base (including retentive/clasping materials, rests and teeth) - Per quadrant

Removable unilateral partial denture – One piece resin base (including retentive/clasping materials, rests and teeth) - Per quadrant

Adjust complete denture – Upper

Adjust complete denture – Lower

Adjust partial denture – Upper

Adjust partial denture – LowerD5422

Repairs to prosthetics

$23.00Repair broken complete denture base - LowerD5511

$23.00Repair broken complete denture base - UpperD5512

$17.00Replace missing or broken teeth – Complete denture (eachtooth)

D5520

$23.00Repair resin partial denture base - LowerD5611

$23.00Repair resin partial denture base - UpperD5612

$23.00Repair cast partial framework - LowerD5621

$23.00Repair cast partial framework - UpperD5622

$23.00Repair or replace broken retentive/clasping materials - Per toothD5630

$17.00Replace broken teeth – Per toothD5640

$23.00Add tooth to existing partial dentureD5650

$32.00Add clasp to existing partial denture - Per toothD5660

$234.00Replace all teeth and acrylic on cast metal framework – UpperD5670


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$234.00Replace all teeth and acrylic on cast metal framework – LowerD5671

Denture relining (limit 1 every 12 months)

$59.00Rebase complete upper dentureD5710

$59.00Rebase complete lower dentureD5711

$59.00Rebase upper partial dentureD5720

$59.00Rebase lower partial dentureD5721

$23.00Reline complete upper denture – DirectD5730

$23.00Reline complete lower denture – DirectD5731

$23.00Reline upper partial denture – DirectD5740

$23.00Reline lower partial denture – DirectD5741

$59.00Reline complete upper denture – IndirectD5750

$59.00Reline complete lower denture – IndirectD5751

$59.00Reline upper partial denture –IndirectD5760

$59.00Reline lower partial denture –IndirectD5761

Interim dentures (limit 1 every 5 years)

$230.00Interim complete denture – UpperD5810

$230.00Interim complete denture – LowerD5811

$41.00Interim partial denture (including retentive/clasping materials,rests and teeth), upper

D5820

$41.00Interim partial denture (including retentive/clasping materials,rests and teeth), lower

D5821

$23.00Tissue conditioning – UpperD5850

$23.00Tissue conditioning – LowerD5851

$160.00Precision attachment – By reportD5862

$260.00Overdenture - complete upperD5863


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$260.00Overdenture - partial upperD5864

$270.00Overdenture - complete lowerD5865

$270.00Overdenture - partial lowerD5866

$65.00Modification of removable prosthesis following implant surgeryD5875

$55.00Add metal substructure to acrylic full denture (per arch)D5876

Implant services

$75.00Replacement of replaceable part of semi-precision or precisionattachment (male or female component) of implant/abutment

D6091

supported prosthesis, per attachment, (limit 1 per consecutiveyear)

Oral surgery (includes routine postoperative treatment)Surgical removal of impacted teeth are covered for ages below 15 when medicallynecessary.

$9.00Extraction of coronal remnants – Primary toothD7111

$9.00Extraction, erupted tooth or exposed root – Elevation and/orforceps removal

D7140

$20.00Extraction, erupted tooth – Removal of bone and/or section oftooth

D7210

$27.00Removal of impacted tooth – Soft tissueD7220

$45.00Removal of impacted tooth – Partially bonyD7230

$68.00Removal of impacted tooth – Completely bonyD7240

$68.00Removal of impacted tooth – Completely bony, unusualcomplications (narrative required)

D7241

$27.00Removal of residual tooth roots – Cutting procedureD7250

$70.00Coronectomy - Intentional partial tooth removalD7251

$110.00Oroantral fistula closureD7260

$110.00Primary closure of a sinus perforationD7261


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$110.00Tooth stabilization of accidentally evulsed or displaced toothD7270

$45.00Exposure of an unerupted tooth (excluding wisdom teeth)D7280

$45.00Placement of device to facilitate eruption of impacted toothD7283

$90.00Incisional biopsy of oral tissue – Hard (bone, tooth) (tooth related– not allowed when in conjunction with another surgical procedure)

D7285

$0.00Incisional biopsy of oral tissue – Soft (all others) (tooth related –not allowed when in conjunction with another surgical procedure)

D7286

$50.00Exfoliative cytological sample collectionD7287

$50.00Brush biopsy – Transepithelial sample collectionD7288

$32.00Alveoloplasty in conjunction with extractions – 4 or more teethor tooth spaces per quadrant

D7310

$21.00Alveoloplasty in conjunction with extractions – 1 to 3 teeth ortooth spaces per quadrant

D7311

$32.00Alveoloplasty not in conjunction with extractions – 4 or moreteeth or tooth spaces per quadrant

D7320

$23.00Alveoloplasty not in conjunction with extractions – 1 to 3 teethor tooth spaces per quadrant

D7321

$0.00Removal of benign odontogenic cyst or tumor – Up to 1.25 cmD7450

$0.00Removal of benign odontogenic cyst or tumor – Greater than1.25 cm

D7451

$80.00Removal of lateral exostosis – Maxilla or mandibleD7471

$60.00Removal of torus palatinusD7472

$60.00Removal of torus mandibularisD7473

$60.00Reduction of osseous tuberosityD7485

$23.00Incision and drainage of abscess – Intraoral soft tissueD7510

$30.00Incision and drainage of abscess – Intraoral soft tissuecomplicated

D7511


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$23.00Incision and drainage of abscess – Extraoral soft tissueD7520

$30.00Incision and drainage of abscess – Extraoral soft tissue –Complicated (includes drainage of multiple fascial spaces)

D7521

$160.00Occlusal orthotic device, by report - (limit 1 per 24 months; onlycovered in conjunction with Temporomandibular Joint (TMJ)treatment)

D7880

$10.00Occlusal orthotic device adjustmentD7881

$0.00Suture of recent small wounds up to 5cmD7910

$0.00Placement of intra-socket biological dressing to aid in hemostasisor clot stabilization, per site

D7922

$60.00Buccal/labial frenectomy (frenulectomy)D7961

$40.00FrenuloplastyD7963

$30.00Excision of hyperplastic tissue - per archD7970

Orthodontics (tooth movement) - Coverage is provided for twenty-four (24) months ofactive treatment. Cases beyond 24 months require an additional payment by the patient.

$140.00Interceptive orthodontic treatment of the primary dentition –Banding

D8050

$140.00Interceptive orthodontic treatment of the transitional dentition– Banding

D8060

$840.00Comprehensive orthodontic treatment of the transitionaldentition – Banding

D8070

$840.00Comprehensive orthodontic treatment of the adolescentdentition – Banding

D8080

$920.00Comprehensive orthodontic treatment of the adult dentition –Banding

D8090

$560.00Removable appliance therapyD8210

$560.00Fixed appliance therapyD8220


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$95.00Pre-orthodontic treatment examination to monitor growth anddevelopment

D8660

Periodic orthodontic treatment visitD8670

Children – Up to 19th birthday:

$960.0024-month treatment fee

$40.00Charge per month for 24 months

$125.00Treatment beyond 24 months - Per month

Adults:

$1,080.0024-month treatment fee

$45.00Charge per month for 24 months

$125.00Treatment beyond 24 months - Per month

$95.00Orthodontic retention – Removal of appliances, constructionand placement of retainer(s)

D8680

$0.00Removable orthodontic retainer adjustmentD8681

$140.00Removal of fixed orthodontic appliances for reasons other thancompletion of treatment

D8695

$0.00Re-cement or re-bond fixed retainer – UpperD8698

$0.00Re-cement or re-bond fixed retainer – LowerD8699

$0.00Repair of fixed retainer, includes reattachment – UpperD8701

$0.00Repair of fixed retainer, includes reattachment – LowerD8702

$270.00Unspecified orthodontic procedure – By report (orthodontictreatment plan and records including all necessary images)

D8999

General anesthesia/IV sedation: coverage is provided when medically necessary forcovered surgical procedures listed on the Patient Charge Schedule. Clinical guidelinesrelated to the use of general anesthesia/IV sedation should be discussed with your treatingnetwork specialist.

$0.00Regional block anesthesiaD9211


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$0.00Trigeminal division block anesthesiaD9212

$0.00Local anesthesiaD9215

$0.00Evaluation for moderate sedation, deep sedation or generalanesthesia

D9219

$45.00Deep sedation/general anesthesia – First 15 minutesD9222

$45.00Deep sedation/general anesthesia – Each subsequent 15 minuteincrement

D9223

$10.00Nitrous oxideD9230

$45.00Intravenous moderate (conscious) sedation/anesthesia – First15 minutes

D9239

$45.00Intravenous moderate (conscious) sedation/analgesia - Eachsubsequent 15 minute increment

D9243

$15.00Therapeutic parenteral drug, single administrationD9610

$25.00Therapeutic parenteral drugs, 2 or more administrations, differentmedications

D9612

$200.00Infiltration of sustained release therapeutic drug – Single ormultiple sites

D9613

$0.00Drugs or medicaments dispensed in the office for home useD9630

$0.00Application of desensitizing medicamentD9910

$0.00Cleaning and inspection of removable complete denture, upperD9932

$0.00Cleaning and inspection of removable complete denture, lowerD9933

$0.00Cleaning and inspection of removable partial denture, upperD9934

$0.00Cleaning and inspection of removable partial denture, lowerD9935

Emergency services

$0.00Palliative (emergency) treatment of dental pain – Minorprocedure

D9110

$0.00Fixed partial denture sectioningD9120


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$35.00Office visit – After regularly scheduled hoursD9440

Miscellaneous services

$110.00Fabrication of athletic mouthguard (limit 1 per 12 months)D9941

$40.00Repair and/or reline of occlusal guardD9942

$10.00Occlusal guard adjustmentD9943

$300.00Occlusal guard – Hard appliance, full arch (limit 1 per 24 months)D9944

$300.00Occlusal guard – Soft appliance, full arch (limit 1 per 24 months)D9945

$300.00Occlusal guard – Hard appliance, partial arch (limit 1 per 24months)

D9946

$0.00Occlusal adjustment – LimitedD9951

$100.00Occlusal adjustment – CompleteD9952

$0.00Duplicate/copy patient's recordsD9961

$125.00External bleaching for home application, per arch; includesmaterials and fabrication of custom trays (all other methods ofbleaching are not covered)

D9975

$0.00Certified translation or sign language services, per visitD9990

$0.00Dental case management - address patient complianceD9991

$0.00Dental case management- care coordinationD9992

$0.00Teledentistry – Synchronous; real-time encounterD9995

$0.00Teledentistry – Asynchronous; information stored and forwardedto dentist for subsequent review

D9996

$0.00Dental case management patients with special healthcare needsD9997

This may contain CDT Dental Procedure Codes and/or portions of, or excerpts from the Codeon Dental Procedures and Nomenclature (CDT Code) contained within the current versionof the “Dental Procedure Codes”, a copyrighted publication provided by the American DentalAssociation. The American Dental Association does not endorse any codes which are notincluded in its current publication.


- 27 -

After your enrollment is effective:

Call the dental office identified in your Welcome Kit. If you wish to changedental offices, a transfer can be arranged at no charge by calling CignaDental at the toll free number listed on your ID card or plan materials.Multiple ways to locate a Network General Dentist:

› On-line provider directory at Cigna.com

› On-line 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: If you have a dental emergency as defined in your group’splan documents, contact your Network General Dentist as soon as possible.If you are out of your service area or unable to contact your NetworkOffice, emergency care can be rendered by any dental office, dental clinic,or other comparable facility. Definitive treatment (e.g., root canal) is notconsidered emergency care and should be performed or referred by yourNetwork General Dentist. Consult your group’s plan documents for acomplete definition of dental emergency, your emergency benefit and alisting of Exclusions and Limitations.

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“Cigna,” “Cigna Dental Care” and the “Tree of Life” logo are registered service marks, ofCigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operatingsubsidiaries. All products and services are provided by or through such operatingsubsidiaries and not by Cigna Corporation. Such operating subsidiaries includeConnecticut General Life Insurance Company (“CGLIC”), Cigna Health and Life InsuranceCompany (“CHLIC”), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc.(“CDHI”) and its subsidiaries. The Cigna Dental Care plan is provided by Cigna DentalHealth Plan of Arizona, Inc.; Cigna Dental Health of California, Inc.; Cigna Dental Healthof Colorado, Inc.; Cigna Dental Health of Delaware, Inc.; Cigna Dental Health of Florida,Inc., a Prepaid Limited Health Services Organization licensed under Chapter636, Florida Statutes; Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska); CignaDental Health of Kentucky, Inc. (Kentucky and Illinois); Cigna Dental Health of Maryland,Inc.; Cigna Dental Health of Missouri, Inc.; Cigna Dental Health of New Jersey, Inc.; CignaDental Health of North Carolina, Inc.; Cigna Dental Health of Ohio, Inc.; Cigna DentalHealth of Pennsylvania, Inc.; Cigna Dental Health of Texas, Inc.; and Cigna Dental Healthof 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.

92438 Subject to Regulatory Approval

955499 a 03/1/2021© 2019 Cigna. Some content provided under license.

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