NJAY2 State of New Jersey Retiree Plan Cigna Dental Care (*DHMO) Patient Charge Schedule
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1 State of New Jersey Retiree Plan Cigna Dental Care (*DHMO) Schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. IMPORTANT HIGHLIGHTS s pay the s 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 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 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 listed when required due to dental or medical necessity in conjunction with covered oral surgery procedures performed by a Network Specialist. 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 s correspond to the 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.
2 Code Procedure Description D0000-D0999 I. 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 $0.00 D0140 Limited oral evaluation Problem focused $0.00 D0145 Oral evaluation for a patient under 3 years of age and counseling with primary $0.00 caregiver D0150 Comprehensive oral evaluation New or established patient $0.00 D0160 Detailed and extensive oral evaluation - problem focused, by report $0.00 Radiographs Bitewing X-rays are limited to two series of up to 4 films per calendar year; set of full mouth X-rays (D0210) are limited to once per 36 month interval; no more than 18 films per set of full mouth X-rays. D0210 Intraoral Complete series of radiographic images $0.00 D0220 Intraoral Periapical first radiographic image $0.00 D0230 Intraoral Periapical each additional radiographic image $0.00 D0240 Intraoral Occlusal radiographic image $0.00 D0250 Extraoral First radiographic image $0.00 D0260 Extraoral Each additional radiographic image $0.00 D0270 Bitewings Single radiographic image $0.00 D0272 Bitewings Two radiographic images $0.00 D0273 Bitewings Three radiographic images $0.00 D0274 Bitewings Four radiographic images $0.00 D0277 Vertical Bitewings Seven to eight radiographic images $0.00
3 D0290 Posterior Anterior or lateral skull and facial bone survey radiographic image $0.00 D0330 Panoramic radiographic image $0.00 D0340 Cephalometric radiographic image $0.00 D0391 Interpretation of diagnostic image by a practitioner not associated with the capture of the image, including report $0.00 Tests and Laboratory Examinations D0415 Collection of microorganisms for culture and sensitivity $0.00 D0416 Viral culture $0.00 D0421 Genetic test for susceptibility to oral diseases $0.00 D0425 Caries susceptibility tests $0.00 D0460 Pulp vitality tests $0.00 D0470 Diagnostic casts $0.00 D1000-D1999 II. Preventive Dental Prophylaxis Limited to two in a Calendar Year D1110 Prophylaxis - Adult $0.00 D1120 Prophylaxis - Child $0.00 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 flouride varnish $0.00 D1208 Topical aplication of fluoride $0.00 Other Preventive Services
4 Code Procedure Description Sealants are limited to once per lifetime for permanent molars of eligible dependent children under the age of 19 years D1330 Oral hygiene instruction $0.00 D1351 Sealant - Per tooth $0.00 D1352 Preventive resin restoration in a moderate to high caries risk patient - $0.00 permanent tooth D1353 Sealant repair $0.00 Space Maintenance (Passive Appliances) D1510 Space Maintainer - Fixed unilateral $0.00 D1515 Space Maintainer - Fixed bilateral $0.00 D1520 Space Maintainer - Removable unilateral $0.00 D1525 Space Maintainer - Removable bilateral $0.00 D1550 Recementation of space maintainer $0.00 D1555 Removal of fixed space retainer $0.00 D2000-D2999 III. 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 Restorations (Including Polishings) D2140 Amalgam One surface, primary or permanent $15.00 D2150 Amalgam Two surfaces, primary or permanent $20.00 D2160 Amalgam Three surfaces, primary or permanent $25.00 D2161 Amalgam Four or more surfaces, primary or permanent $30.00 Resin Restorations D2330 Resin-based composite One surface, anterior $25.00 D2331 Resin-based composite Two surfaces, anterior $30.00
5 D2332 Resin-based composite Three surfaces, anterior $35.00 D2335 Resin-based composite Four or more surfaces or involving incisal angle (Anterior) Incisal Angle Anterior $45.00 D2390 Resin-based composite crown Anterior $55.00 D2391 Resin-based composite One surface, posterior $25.00 D2392 Resin-based composite Two surfaces, posterior $40.00 D2393 Resin-based composite Three surfaces, posterior $55.00 D2394 Resin-based composite Four or more surfaces, posterior $70.00 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 $160.00
6 D2651 Inlay Resin-based composite Two surfaces $ D2652 Inlay Resin-based composite Three or more surfaces $ D2662 Onlay Resin-based composite Two surfaces $ D2663 Onlay Resin-based composite Three surfaces $ D2664 Onlay Resin-based composite Four or more surfaces $ Crowns Single Restorations Only D2710 Crown Resin-based composite (Indirect) (see note below) $ D2720 Crown Resin with high noble metal $ D2721 Crown Resin with predominantly base metal $ D2722 Crown Resin with noble metal $ D2740 Crown Porcelain/ceramic substrate $ D2750 Crown Porcelain fused to high noble metal $ D2751 Crown Porcelain fused to predominantly base metal $ D2752 Crown Porcelain fused to noble metal $ D2780 Crown 3/4 cast high noble metal $ D2781 Crown 3/4 cast predominantly base metal $ D2790 Crown Full cast high noble metal $ D2791 Crown Full cast predominantly base metal $ D2792 Crown Full cast noble metal $ D2794 Crown Titanium $ Note: There is no copayment for procedure D2710 when performed in conjunction with a permanent crown on the same tooth. Other Restorative Services
7 D2910 Recement inlay, onlay, or partial coverage restoration $15.00 D2915 Recement cast or prefabricated post and core $15.00 D2920 Recement crown $15.00 D2921 Reattachment of tooth fragment, incisal edge or cusp $0.00 D2929 Prefabricated porcelain/ceramic crown Primary tooth $69.00 D2930 Prefabricated stainless steel crown Primary tooth $55.00 D2931 Prefabricated stainless steel crown Permanent tooth $55.00 D2932 Prefabricated resin crown $55.00 D2933 Prefabricated stainless steel crown with resin window $55.00 D2934 Prefabricated esthetic coated stainless steel crown Primary tooth $55.00 D2940 Protective restoration $20.00 D2941 Interim therapeutic restoration - Primary dentition $0.00 D2950 Core buildup, including any pins when required $45.00 D2951 Pin retention Per tooth in addition to restoration $15.00 D2952 Cast post and core in addition to crown $60.00 D2954 Prefabricated post and core in addition to crown $60.00 D2955 Post removal $45.00 D2971 Additional procedures to construct new crown under existing partial denture $20.00 framework D2980 Crown repair necessitated by restorative material failure $15.00 D2981 Inlay repair necessitated by restorative material failure $15.00 D2982 Onlay repair necessitated by restorative material failure $15.00 D2983 Veneer repair necessitated by restorative material failure $15.00
8 D2990 Resin infiltration of incipient smooth surface lesions $15.00
9 *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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