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Summary Plan Description (SPD)
B1-05 Patient Charge Schedule
| Code |
|
B1-05 | |
|
|
DIAGNOSTIC/PREVENTIVE |
|
|
| D9310 | Consultation (Diagnostic Service Provided By Dentist or Physician Other Than Practitioner Providing Treatment) | $0.00 | |
| D9430 | Office Visit for Observation (During Regularly Scheduled Hours) - No Other Services Performed | $0.00 | |
| D9450 | Case Presentation, Detailed and Extensive Treatment Planning | $0.00 | |
| D0120 | Periodic Oral Evaluation | $0.00 | |
| D0140 | Limited Oral Evaluation - Problem Focused | $0.00 | |
| D0150 | Comprehensive Oral Evaluation - New or Established Patient | $0.00 | |
| D0170 | Re-evaluation - Limited, Problem Focused (Established Patient; Not Post-Operative Visit) | $0.00 | |
| D0210 | X-Rays Intraoral - Complete Series (including bitewings) (Limit 1 Every 3 Years) | $0.00 | |
| D0220 | X-Rays Intraoral - Periapical First Film | $0.00 | |
| D0230 | X-Rays Intraoral - Periapical Each Additional Film | $0.00 | |
| D0240 | X-Rays Intraoral - Occlusal Film | $0.00 | |
| D0270 | X-Rays (Bitewing) - Single Film | $0.00 | |
| D0272 | X-Rays (Bitewings) - Two Films | $0.00 | |
| D0274 | X-Rays (Bitewings) - Four Films | $0.00 | |
| D0277 | X-Rays (Bitewings, Vertical) - 7 to 8 Films | $0.00 | |
| D0330 | X-Rays (Panoramic Film) - (Limit 1 every 3 years) | $0.00 | |
| D0460 | Pulp Vitality Tests | $0.00 | |
| D0470 | Diagnostic Casts | $0.00 | |
| D0472 | Accession of Tissue, Gross Examination, Preparation and Transmission of Written Report | $0.00 | |
| D0473 | Accession of Tissue, Gross and Microscopic Examination, Preparation and Transmission of Written Report | $0.00 | |
| D0474 | Accession of Tissue, Gross and Microscopic Examination, Including Assessment of Surgical Margins for Presence of Disease, Preparation and Transmission of Written Report | $0.00 | |
| D1110 | Prophylaxis - Adult (Limit 1 Every 6 Months) | $0.00 | |
|
|
(Additional Prophylaxis, In Addition to the 1 Prophylaxis Allowed Every 6 Months) | $41.00 | |
| D1120 | Prophylaxis - Child (Limit 1 Every 6 Months) | $0.00 | |
|
|
(Additional Prophylaxis, In Addition to the 1 Prophylaxis Allowed Every 6 Months) | $30.00 | |
| D1203 | Topical Application of Fluoride - (prophylaxis not included) - Child (Up to 19th Birthday) (Limit 1 Every 6 Months) | $0.00 | |
| D1330 | Oral Hygiene Instructions | $0.00 | |
| D1351 | Sealant - Per Tooth - (Up to 14th Birthday) | $0.00 | |
| D1510 | Space Maintainer - Fixed - Unilateral | $0.00 | |
| D1515 | Space Maintainer - Fixed - Bilateral | $0.00 | |
|
|
RESTORATIVE (FILLINGS) |
|
|
| D2140 | Amalgam - One Surface, Primary or Permanent | $0.00 | |
| D2150 | Amalgam - Two Surfaces, Primary or Permanent | $0.00 | |
| D2160 | Amalgam - Three Surfaces, Primary or Permanent | $0.00 | |
| D2161 | Amalgam - Four or More Surfaces, Primary or Permanent | $0.00 | |
| D2330 | Resin-Based Composite - One Surface, Anterior | $0.00 | |
| D2331 | Resin-Based Composite - Two Surfaces, Anterior | $0.00 | |
| D2332 | Resin-Based Composite - Three Surfaces, Anterior | $0.00 | |
| D2335 | Resin-Based Composite - Four or More Surfaces or Involving Incisal Angle (Anterior) | $75.00 | |
| D2390 | Resin-Based Composite Crown, Anterior | $25.00 | |
| D2391 | Resin-Based Composite - One Surface, Posterior | $35.00 | |
| D2392 | Resin-Based Composite - Two Surfaces, Posterior | $45.00 | |
| D2393 | Resin-Based Composite - Three Surfaces, Posterior | $65.00 | |
| D2394 | Resin-Based Composite - Four or More Surfaces, Posterior | $85.00 | |
|
|
CROWN AND BRIDGE |
|
|
| D2510 | Inlay - Metallic - One Surface | $220.00 | |
| D2520 | Inlay - Metallic - Two Surfaces | $220.00 | |
| D2530 | Inlay - Metallic - Three or More Surfaces | $220.00 | |
| D2542 | Onlay - Metallic - Two Surfaces | $190.00 | |
| D2543 | Onlay - Metallic - Three Surfaces | $190.00 | |
| D2544 | Onlay - Metallic - Four or More Surfaces | $190.00 | |
| D2740 | Crown - Porcelain/Ceramic Substrate | $220.00 | |
| D2750 | Crown - Porcelain Fused to High Noble Metal | $210.00 | |
| D2751 | Crown - Porcelain Fused to Predominantly Base Metal | $165.00 | |
| D2752 | Crown - Porcelain Fused to Noble Metal | $200.00 | |
| D2780 | Crown - 3/4 Cast High Noble Metal | $210.00 | |
| D2781 | Crown - 3/4 Cast Predominantly Base Metal | $165.00 | |
| D2782 | Crown - 3/4 Cast Noble Metal | $200.00 | |
| D2790 | Crown - Full Cast High Noble Metal | $210.00 | |
| D2791 | Crown - Full Cast Predominantly Base Metal | $165.00 | |
| D2792 | Crown - Full Cast Noble Metal | $200.00 | |
| D2910 | Recement Inlay | $0.00 | |
| D2920 | Recement Crown | $0.00 | |
| D2930 | Prefabricated Stainless Steel Crown - Primary Tooth | $0.00 | |
| D2931 | Prefabricated Stainless Steel Crown - Permanent Tooth | $0.00 | |
| D2932 | Prefabricated Resin Crown | $50.00 | |
| D2933 | Prefabricated Stainless Steel Crown with Resin Window | $70.00 | |
| D2940 | Sedative Filling | $0.00 | |
| D2950 | Core Buildup, Including Any Pins | $40.00 | |
| D2951 | Pin Retention - Per Tooth, In Addition to Restoration | $0.00 | |
| D2952 | Cast Post and Core, In Addition to Crown | $65.00 | |
| D2954 | Prefabricated Post and Core In Addition to Crown | $55.00 | |
| D2960 | Labial veneer (Resin Laminate) - Chairside | $75.00 | |
| D6210 | Pontic - Cast High Noble Metal | $210.00 | |
| D6211 | Pontic - Cast Predominantly Base Metal | $165.00 | |
| D6212 | Pontic - Cast Noble Metal | $200.00 | |
| D6240 | Pontic - Porcelain Fused to High Noble Metal | $210.00 | |
| D6241 | Pontic - Porcelain Fused to Predominantly Base Metal | $165.00 | |
| D6242 | Pontic - Porcelain Fused to Noble Metal | $200.00 | |
| D6245 | Pontic - Porcelain/Ceramic | $185.00 | |
| D6602 | Inlay - Cast High Noble Metal, Two Surfaces | $210.00 | |
| D6603 | Inlay - Cast High Noble Metal, Three or More Surfaces | $210.00 | |
| D6604 | Inlay - Cast Predominantly Base Metal, Two Surfaces | $165.00 | |
| D6605 | Inlay - Cast Predominantly Base Metal, Three or More Surfaces | $165.00 | |
| D6606 | Inlay - Cast Noble Metal, Two Surfaces | $200.00 | |
| D6607 | Inlay - Cast Noble Metal, Three or More Surfaces | $200.00 | |
| D6610 | Onlay - Cast High Noble Metal, Two Surfaces | $210.00 | |
| D6611 | Onlay - Cast High Noble Metal, Three or More Surfaces | $210.00 | |
| D6612 | Onlay - Cast Predominantly Base Metal, Two Surfaces | $165.00 | |
| D6613 | Onlay - Cast Predominantly Base Metal, Three or More Surfaces | $165.00 | |
| D6614 | Onlay - Cast Noble Metal, Two Surfaces | $200.00 | |
| D6615 | Onlay - Cast Noble Metal, Three or More Surfaces | $200.00 | |
| D6740 | Crown - Porcelain/Ceramic | $220.00 | |
| D6750 | Crown - Porcelain Fused to High Noble Metal | $210.00 | |
| D6751 | Crown - Porcelain Fused to Predominantly Base Metal | $165.00 | |
| D6752 | Crown - Porcelain Fused to Noble Metal | $200.00 | |
| D6780 | Crown - 3/4 Cast High Noble Metal | $210.00 | |
| D6781 | Crown - 3/4 Cast Predominantly Base Metal | $165.00 | |
| D6782 | Crown - 3/4 Cast Noble Metal | $200.00 | |
| D6790 | Crown - Full Cast High Noble Metal | $210.00 | |
| D6791 | Crown - Full Cast Predominantly Base Metal | $165.00 | |
| D6792 | Crown - Full Cast Noble Metal | $200.00 | |
| Complex Rehabilitation - ADDITIONAL CHARGE PER UNIT AFTER 5 UNITS FOR MULTIPLE CROWN UNITS/COMPLEX REHABILITATION | $125.00 | ||
| D6930 | Recement Fixed Partial Denture | $0.00 | |
|
|
ENDODONTICS |
|
|
| D3110 | Pulp Cap - Direct (Excluding Final Restoration) | $0.00 | |
| D3120 | Pulp Cap - Indirect (Excluding Final Restoration) | $0.00 | |
| D3220 | Therapeutic Pulpotomy (Excluding Final Restoration)- Removal of Pulp Coronal to the Dentinocemental Junction and Application of Medicament | $10.00 | |
| D3221 | Pulpal Debridement, Primary and Permanent Teeth (Not to be Used by Provider Completing Endodontic Treatment) | $10.00 | |
| D3310 | Anterior Root Canal (Permanent Tooth) (Excluding Final Restoration) | $0.00 | |
| D3320 | Bicuspid Root Canal (Permanent Tooth) (Excluding Final Restoration) | $20.00 | |
| D3330 | Molar Root Canal (Permanent Tooth) (Excluding Final Restoration) | $135.00 | |
| D3331 | Treatment of Root Canal Obstruction; Non-Surgical Access | $0.00 | |
| D3332 | Incomplete Endodontic Therapy; Inoperable or Fractured Tooth | $0.00 | |
| D3333 | Internal Root Repair of Perforation Defects | $0.00 | |
| D3346 | Retreatment of Previous Root Canal Therapy - Anterior | $0.00 | |
| D3347 | Retreatment of Previous Root Canal Therapy - Bicuspid | $20.00 | |
| D3348 | Retreatment of Previous Root Canal Therapy - Molar | $170.00 | |
| D3410 | Apicoectomy/Periradicular Surgery - Anterior | $0.00 | |
| D3421 | Apicoectomy/Periradicular Surgery - Bicuspid (First Root) | $0.00 | |
| D3425 | Apicoectomy/Periradicular Surgery - Molar (First Root) | $0.00 | |
| D3426 | Apicoectomy/Periradicular Surgery (Each Additional Root) | $0.00 | |
| D3430 | Retrograde Filling - Per Root | $0.00 | |
|
|
PERIODONTICS |
|
|
| D0180 | Comprehensive Periodontal Evaluation - New or Established Patient | $15.00 | |
| D4210 | Gingivectomy or Gingivoplasty - Four or More Contiguous Teeth or Bounded Teeth Spaces Per Quadrant | $75.00 | |
| D4211 | Gingivectomy or Gingivoplasty - One to Three Teeth, Per Quadrant | $40.00 | |
| D4240 | Gingival Flap Procedure, Including Root Planing - Four or More Contiguous Teeth or Bounded Teeth Spaces Per Quadrant | $85.00 | |
| D4241 | Gingival Flap Procedure, Including Root Planing - One to Three Teeth, Per Quadrant | $45.00 | |
| D4245 | Apically Positioned Flap | $85.00 | |
| D4249 | Clinical Crown Lengthening - Hard Tissue | $65.00 | |
| D4260 | Osseous Surgery - Including Flap Entry and Closure -Four or More Contiguous Teeth or Bounded Teeth Spaces Per Quadrant | $130.00 | |
| D4261 | Osseous Surgery - Including Flap Entry and Closure -One to Three Teeth, Per Quadrant | $65.00 | |
| D4263 | Bone Replacement Graft - First Site in Quadrant | $225.00 | |
| D4264 | Bone Replacement Graft - Each Additional Site in Quadrant | $175.00 | |
| D4266 | Guided Tissue Regeneration - Resorbable Barrier, Per Site | $295.00 | |
| D4267 | Guided Tissue Regeneration - Nonresorbable Barrier, Per Site (Includes Membrane Removal) | $335.00 | |
| D4270 | Pedicle Soft Tissue Graft Procedure | $70.00 | |
| D4271 | Free Soft Tissue Graft Procedure (Including Donor Site Surgery) | $70.00 | |
| D4275 | Soft Tissue Allograft | $70.00 | |
| D4341 | Periodontal Scaling and Root Planing, Four or More Contiguous Teeth or Bounded Teeth Spaces Per Quadrant (Limit 4 Quadrants per Consecutive 12 Months) | $30.00 | |
| D4342 | Periodontal Scaling and Root Planing- One to Three Teeth, Per Quadrant (Limit 4 Quadrants per Consecutive 12 Months) | $15.00 | |
| D4355 | Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis | $30.00 | |
| D4381 | Localized Delivery of Chemotherapeutic Agents Via A Controlled Release Vehicle Into Diseased Crevicular Tissue, Per Tooth, By Report | $60.00 | |
| D4910 | Periodontal Maintenance (Limit of 2 Within the First 12 Months After Active Therapy) | $20.00 | |
| D9940 | Occlusal Guard - By Report | $70.00 | |
| D9951 | Occlusal Adjustment - Limited | $20.00 | |
| D9952 | Occlusal Adjustment - Complete | $55.00 | |
|
|
PROSTHETICS |
|
|
| D5110 | Complete Denture - Maxillary | $280.00 | |
| D5120 | Complete Denture - Mandibular | $280.00 | |
| D5130 | Immediate Denture - Maxillary | $280.00 | |
| D5140 | Immediate Denture - Mandibular | $280.00 | |
| D5211 | Maxillary Partial Denture - Resin Base (Including Any Conventional Clasps, Rests and Teeth) | $210.00 | |
| D5212 | Mandibular Partial Denture - Resin Base (Including Any Conventional Clasps, Rests and Teeth) | $210.00 | |
| D5213 | Maxillary Partial Denture - Cast Metal Framework with Resin Denture Bases (Including Any Conventional Clasps, Rests and Teeth) | $325.00 | |
| D5214 | Mandibular Partial Denture - Cast Metal Framework with Resin Denture Bases (Including Any Conventional Clasps, Rests and Teeth) | $325.00 | |
| D5410 | Adjust Complete Denture - Maxillary | $15.00 | |
| D5411 | Adjust Complete Denture - Mandibular | $15.00 | |
| D5421 | Adjust Partial Denture - Maxillary | $15.00 | |
| D5422 | Adjust Partial Denture - Mandibular | $15.00 | |
|
|
REPAIRS TO PROSTHETICS |
|
|
| D5510 | Repair Broken Complete Denture Base | $35.00 | |
| D5520 | Replace Missing or Broken Teeth - Complete Denture (Each Tooth) | $35.00 | |
| D5610 | Repair Resin Denture Base | $35.00 | |
| D5630 | Repair or Replace Broken Clasp | $45.00 | |
| D5640 | Replace Broken Teeth - Per Tooth | $35.00 | |
| D5650 | Add Tooth to Existing Partial Denture | $35.00 | |
| D5660 | Add Clasp to Existing Partial Denture | $45.00 | |
|
|
DENTURE RELINING |
|
|
| D5710 | Rebase Complete Maxillary Denture | $100.00 | |
| D5711 | Rebase Complete Mandibular Denture | $100.00 | |
| D5720 | Rebase Maxillary Partial Denture | $100.00 | |
| D5721 | Rebase Mandibular Partial Denture | $100.00 | |
| D5730 | Reline Complete Maxillary Denture (Chairside) | $0.00 | |
| D5731 | Reline Complete Mandibular Denture (Chairside) | $0.00 | |
| D5740 | Reline Maxillary Partial Denture (Chairside) | $0.00 | |
| D5741 | Reline Mandibular Partial Denture (Chairside) | $0.00 | |
| D5750 | Reline Complete Maxillary Denture (Laboratory) | $85.00 | |
| D5751 | Reline Complete Mandibular Denture (Laboratory) | $85.00 | |
| D5760 | Reline Maxillary Partial Denture (Laboratory) | $85.00 | |
| D5761 | Reline Mandibular Partial Denture (Laboratory) | $85.00 | |
|
|
INTERIM DENTURES |
|
|
| D5810 | Interim Complete Denture (Maxillary) | $150.00 | |
| D5811 | Interim Complete Denture (Mandibular) | $150.00 | |
| D5820 | Interim Partial Denture - (Maxillary) | $120.00 | |
| D5821 | Interim Partial Denture - (Mandibular) | $120.00 | |
|
|
ORAL SURGERY |
|
|
| D7111 | Coronal Remnants - Deciduous Tooth | $5.00 | |
| D7140 | Extraction, Erupted Tooth or Exposed Root (Elevation and/or Forceps Removal) | $5.00 | |
| D7210 | Surgical Removal of Erupted Tooth Requiring Elevation of Mucoperiosteal Flap and Removal of Bone and/or Section of Tooth | $10.00 | |
| D7220 | Removal of Impacted Tooth - Soft Tissue | $10.00 | |
| D7230 | Removal of Impacted Tooth - Partially Bony | $20.00 | |
| D7240 | Removal of Impacted Tooth - Completely Bony | $45.00 | |
| D7241 | Removal of Impacted Tooth - Completely Bony, With Unusual Surgical Complications | $45.00 | |
| D7250 | Surgical Removal of Residual Tooth Roots (Cutting Procedure) | $10.00 | |
| D7260 | Oroantral Fistula Closure | $45.00 | |
| D7261 | Primary Closure of a Sinus Perforation | $45.00 | |
| D7270 | Tooth Reimplantation and/or stabilization of accidentally evulsed or displaced tooth | $0.00 | |
| D7280 | Surgical Access of an Unerupted Tooth (Excluding Wisdom Teeth) | $0.00 | |
| D7281 | Surgical Exposure of Impacted or Unerupted Tooth to Aid Eruption | $0.00 | |
| D7285 | Biopsy of Oral Tissue - Hard (Bone, Tooth) (Tooth Related - Not allowed when in conjunction with another surgical procedure) | $40.00 | |
| D7286 | Biopsy of Oral Tissue - Soft (All Others) (Tooth Related - Not allowed when in conjunction with another surgical procedure) | $30.00 | |
| D7310 | Alveoplasty in Conjunction with Extractions - Per Quadrant | $0.00 | |
| D7320 | Alveoplasty Not in Conjunction with Extractions - Per Quadrant | $0.00 | |
| D7450 | Removal of Benign Odontogenic Cyst or Tumor - Lesion Diameter Up to 1.25cm | $0.00 | |
| D7451 | Removal of Benign Odontogenic Cyst or Tumor - Lesion Diameter Greater Than 1.25cm | $0.00 | |
| D7471 | Removal of Lateral Exostosis (Maxilla or Mandible) | $0.00 | |
| D7472 | Removal of Torus Palatinus | $0.00 | |
| D7473 | Removal of Torus Mandibularis | $0.00 | |
| D7485 | Surgical Reduction of Osseous Tuberosity | $0.00 | |
| D7510 | Incision and Drainage of Abscess - Intraoral Soft Tissue | $0.00 | |
| D7960 | Frenulectomy (Frenectomy or Frenotomy) - Separate procedure | $0.00 | |
|
|
ORTHODONTICS |
|
|
| D8050 | Interceptive Orthodontic Treatment of the Primary Dentition (Banding) | $375.00 | |
| D8060 | Interceptive Orthodontic Treatment of the Transitional Dentition (Banding) | $375.00 | |
| D8070 | Comprehensive Orthodontic Treatment of the Transitional Dentition (Banding) | $400.00 | |
| D8080 | Comprehensive Orthodontic Treatment of the Adolescent Dentition (Banding) | $400.00 | |
| D8090 | Comprehensive Orthodontic Treatment of the Adult Dentition (Banding) | $400.00 | |
| D8660 | Pre-Orthodontic Treatment Visit | $40.00 | |
| D8670 | Periodic Orthodontic Treatment Visit (As Part of Contract) |
|
|
|
|
Children (Up to 19th Birthday) | $50.00 | |
|
|
Adults | $75.00 | |
| D8680 | Orthodontic Retention (Removal of Appliances, Construction and Placement of Retainer(s)) | $300.00 | |
| D8999 | Unspecified Orthodontic Procedure, By Report (Orthodontic Treatment Plan and Records) | $150.00 | |
|
|
GENERAL ANESTHESIA/I.V. SEDATION |
|
|
| D9220 | Deep Sedation/General Anesthesia - First 30 Minutes ) | $130.00 | |
| D9221 | Deep Sedation/General Anesthesia - Each Additional 15 Minutes | $65.00 | |
| D9241 | Intravenous Conscious Sedation/Analgesia - First 30 Minutes | $130.00 | |
| D9242 | Intravenous Conscious Sedation/Analgesia - Each Additional 15 Minutes | $65.00 | |
|
|
EMERGENCY SERVICES |
|
|
| D9110 | Palliative (Emergency) Treatment of Dental Pain - Minor Procedure | $0.00 | |
| D9440 | Office Visit - After Regularly Scheduled Hours |
$54.00 |
|
|
|
|
||
After Your Enrollment Is Effective:
Call the dental office identified in your Welcome Kit information. If you wish to change dental offices, a transfer can be arranged at no charge by calling CIGNA Dental Health at 1-800-367-1037. EMERGENCY: If a dental emergency as defined in your group agreement/member materials arises, 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 agreement and/or member booklet/certificate for a complete definition of dental emergency, your emergency benefit and a listing of Exclusions and Limitations.