To: Valued Members and Providers From: Member Services Date: January 2019 RE: Attached is the for all members. Note: The Plan Pays amount on the fee schedule already has the percentages factored in. The member will be responsible for any balance due beyond what pays. does not contract with a network of dentists, so members may select a dentist of their choice. Please note a few important reminders to help expedite the process of dental claims/estimates: s Electronic Payer ID # is 38238, Group #: R40. Required documentation, including x-ray images, must be submitted on paper o Periodontal work full-mouth x-rays and charting o Soft tissue grafts - a narrative statement and charting o Bony impactions - a panorex x-ray o Completed endodontic work post-op periapical x-rays o Prosthetics a pre-op periapical x-ray, narrative statement for recommended crown; and x-ray of completed crown o Adult orthodontic treatment - x-rays and issue being corrected All wisdom teeth claims/estimates need to be submitted to dental first (Codes: D7230, D7240, D7241). Once the claim is paid through the dental plan, we will forward the balance to CIGNA who pays as secondary. If you have any questions, please call 1-800-258-9732 to speak with Amie at extension 233 or Ann at extension 229.
DIAGNOSTIC EXAMINATIONS FILLINGS (cont.) 0120 periodic exam 51 2150 two surfaces 145 0150 initial exam 98 2160 three surfaces 179 0140 emergency exam 91 2161 four surfaces or more 206 0145 oral evaluation under 3 yrs. of age 80 Composite Resin permanent or primary 0160 problem focused 118 2330 one surface 136 9110 palliative treatment 135 2331 two surfaces 163 9310 consultation (per session) 123 2332 three surfaces 204 9311 consultation with medical health care professional 123 2335 four surfaces and incisors 249 X-RAYS AND LAB 2390 resin based composite crown 276 0210 full mouth X-rays 148 2391 one surface 153 0220 intraoral X-ray first 33 2392 two surfaces 199 0230 intraoral X-ray each additional 27 2393 three surfaces 246 0240 occlusal X-rays 43 2394 four surfaces 292 0270 bitewing-1 33 2921 reattachment of tooth fragment 179 0272 bitewing-2 52 2930 stainless steel crown-primary tooth only 248 0273 bitewing-3 58 2931 stainless steel crown-permanent tooth only 246 0274 bitewing-4 72 2940 protective restoration/sedative filling 112 0277 vertical bitewing 103 2951 pin retention (per tooth) 55 0330 panorex X-ray 133 PERIODONTICS 0364 cone beam CT(< than 1 whole jaw) - by report 300 0180 periodontal consultations 90 0365 cone beam CT(1 full lower arch ) -by report 300 4210 gingivectomy per quadrant (4 or more teeth) 524 0366 cone beam CT(1 full upper arch) - by report 300 4211 gingivectomy (2 to 3 teeth) 262 0367 cone beam CT (view of both jaws) - by report 300 4212 gingivectomy (1 tooth) 175 PREVENTIVE 4220 subgingival curettage-per quadrant 175 CLEANING AND FLOURIDE TREATMENTS 4230 crown exposure-per quadrant 501 1110 cleaning-age 13 to adult 103 4231 crown exposure (1-3 teeth) 275 1120 cleaning-child through age 12 82 4240 gingival flap per quadrant (4 or more teeth) 600 1206 topical fluoride varnish-through age 18 44 4241 gingival flap (1 tooth) 200 1208 fluoride-child through age 18 44 4242 gingival flap (2 to 3 teeth) 300 1351 sealants-child through age 18 61 4249 crown lengthening 790 1352 resin-sealant/permanent tooth-through age 18 80 4260 osseous surgery-per quadrant 888 1353 sealant repair (per tooth/permanent) 52 4261 osseous surgery (1 tooth) 296 SPACE MAINTAINERS (up to age 14) 4262 osseous surgery (2 to 3 teeth) 444 1510 fixed unilateral 376 4263 bone graft-first site 468 1516 fixed-bilateral-maxillary 530 4264 bone graft-each additional site 222 1517 fixed-bilateral-mandibular 530 4265 biologic materials/tissue regeneration 450 1520 removable unilateral 460 4266 tissue regeneration/resorbable 500 1526 removable bilateral-maxillary 460 4267 tissue regeneration/nonresorbable 508 1527 removable bilateral-mandibular 460 4270 pedicle soft tissue graft-per report 812 1550 recementation (once per year) 61 4273 connective tissue graft- per report 1,000 1575 distal shoe space maintainer - fixed unilateral 376 4274 mesial/distall wedge procedure single tooth 554 GUARDS (one type of guard once every 5 years) 4275 non-autogenous connective tissue graft 824 9941 athletic guard 261 4276 combined connective tissue graft 837 9944 occlusal guard-hard appliance-full arch 484 4277 free soft tissue graft-per report 855 9945 occlusal guard-soft appliance-full arch 484 4278 free soft tissue graft (larger) per report 855 9946 occlusal guard-hard appliance-partial arch 484 4341 periodontal scaling/root planing-per quadrant 212 9943 occlusal guard adjustment 51 4342 periodontal scaling /root planing (1 tooth) 71 BASIC CARE 4343 periodontal scaling /root planing (2 to 3 teeth) 106 FILLINGS 4346 scaling/gingival inflammation/full mouth 103 Amalgam permanent or primary 4355 difficult prophylaxis/scaling 103 2140 one surface 115 4910 periodontal maintenance procedure 103 Revised December 2018 Page 1 of 4
ENDODONTICS ORAL SURGERY (cont.) 3110 pulp capping/remineralization 65 7951 sinus augmentation by report 3220 vital pulpotomy 155 7952 sinus augmentation vertical approach by report 3221 pulpal debridement (primary & permanent) 177 7953 bone replacement graft for implants 443 3230 pulpal therapy-anterior primary tooth 178 7960 frenectomy 345 3240 pulpal therapy-posterior primary tooth 153 7963 frenuloplasty 254 Root Canal Therapy 7970 excision of hyperplastic tissue 403 3310 one root 716 7971 excision of pericoronal gingiva 199 3320 two roots 838 7979 non-surgical sialo lithotomy by report 3330 three roots 1,015 7980 surgical sialo lithotomy by report 3340 3352 four roots apexification/recalcification 1,150 9222 9239 3351 3353 apexification per visit apexification final visit /9223 /9243 general anesthesia - total benefit of all increments IV sedation - total benefit of all increments 500 460 3357 pulpal regeneration completion of treatment 100 MAJOR CARE Apicoectomy CROWNS AND BRIDGES 3410 anterior 537 2510 metallic inlay-1 surface 330 3421 bicuspid 599 2520 metallic inlay-2 surfaces 381 3425 molar 673 2530 metallic inlay-3 or more surfaces 457 3426 each additional root 335 2543 metallic onlay-3 surfaces 377 3430 retrograde filling-per root 208 2544 metallic onlay-4 or more surfaces 441 3450 root resection 250 2610 porcelain/ceramic inlay-1 surface 359 3920 hemi section 203 2620 porcelain/ceramic inlay-2 surfaces 406 EXTRACTIONS 2630 porcelain/ceramic inlay-3 or more surfaces 426 7111 coronal remnants-primary tooth 100 2642 porcelain/ceramic onlay-2 surfaces 432 7140 single tooth 154 2643 porcelain/ceramic onlay-3 surfaces 578 7130 root removal-exposed root 117 2644 porcelain/ceramic onlay-4 or more surfaces 605 SURGICAL EXTRACTIONS 2650 inlay-composite/resin-1 surface 422 7210 erupted tooth 256 2651 inlay-composite/resin-2 surfaces 432 7220 soft tissue impaction 320 2652 inlay-composite/resin-3 or more surfaces 443 7230 partial bony impaction 390 2662 onlay-composite/resin-2 surfaces 432 7240 complete bony impaction 428 2663 onlay-composite/resin-3 surfaces 443 7241 complete bony impaction-difficult 446 2664 onlay-composite/resin-4 or more surfaces 508 7250 residual root recovery 263 2710 plastic crown (laboratory) 203 ORAL SURGERY 2740 porcelain crown 652 7260 oroantral fistula closure by report 2750 porcelain to high noble metal 633 7280 surgical exposure of ortho 440 2751 porcelain with nonprecious metal 535 7281 surgical exposure of unerupted tooth 440 2752 porcelain with semiprecious metal 600 7283 device to facilitate eruption of impacted tooth 173 2780 three-quarter high noble metal 633 7285 biopsy oral tissue-hard 290 2781 three-quarter predominantly base metal 472 7286 biopsy oral tissue-soft 307 2782 three-quarter cast noble metal 633 7288 brush biopsy 143 2783 three-quarter crown/porcelain 658 7295 autogenous grafting/harvest of bone 441 2790 gold crown - full cast 645 7296 corticotomy-1 to 3 tooth spaces, per quadrant by report 2791 nonprecious crown 498 7297 corticotomy-4 or more tooth spaces, per quadrant by report 2792 semiprecious crown 547 7310 alveoplasty (per quadrant w/extractions) 275 2794 titanium crown 580 7320 alveoplasty (per quadrant w/no extractions) 305 2810 three-quarter cast crown-metallic 540 7340 vestibuloplasty (per arch, uncomplicated) 216 2910 recement or re-bond inlay or onlay 60 7350 vestibuloplasty (per arch, w/ridge extension) 338 2920 recement or re-bond crown 65 7430 cystectomy 270 2932 prefabricated resin crown 154 7471 removal of exostosis 330 2950 crown build-up pin retained 160 7510 incision and drainage abscess-intraoral 221 2952 cast post and core, in addition to crown 223 7520 incision and drainage abscess-extraoral 300 2954 prefabricated post and core 187 7950 osseous or cartilage graft by report 2955 post removal 53 Revised December 2018 Page 2 of 4
MAJOR CARE (cont.) MAJOR CARE (cont.) CROWNS AND BRIDGES (cont.) DENTURES (cont.) 2980 crown repair 130 Adjustments 2981 inlay repair 130 5410 complete upper denture 47 2982 onlay repair 130 5411 complete lower denture 47 6210 high noble metal pontic 633 5421 upper partial 47 6211 cast predominantly base pontic 535 5422 lower partial 47 6212 cast noble metal pontic 600 Repairs 6214 titanium pontic 580 5511 repair complete denture base, mandibular 100 6240 porcelain fused to high noble pontic 633 5512 repair complete denture base, maxillary 100 6241 porcelain to predominantly base pontic 535 5520 replace tooth 87 6242 porcelain to noble metal pontic 633 5611 repair resin partial denture base, mandibular 100 6245 porcelain to ceramic pontic 652 5612 repair resin partial denture base, maxillary 100 6545 cast metal retainer 355 5621 repair cast partial framework, mandibular 100 6548 porcelain to ceramic retainer 355 5622 repair cast partial framework, maxillary 100 6549 resin retainer 355 5630 repair or replace broken clasps (per tooth) 127 6740 porcelain to ceramic abutment 652 5640 broken tooth on partial (no other repairs) 90 6750 porcelain to gold abutment 633 5650 add tooth to partial 112 6751 porcelain to nonprecious abutment 535 5660 add clasp to existing partial (per tooth) 91 6752 porcelain to semiprecious abutment 591 Rebase 6790 high noble full cast abutment 645 5710 complete upper denture 228 6791 predominantly base full cast abutment 498 5711 complete lower denture 228 6792 noble metal full cast abutment 645 5720 upper partial denture 228 6794 titanium abutment 580 5721 lower partial denture 228 6930 recement bridge 91 Office Reline 6980 bridge repair 178 5730 complete upper denture 193 IMPLANT CROWNS 5731 complete lower denture 193 6058 abutment supported porcelain/ceramic 652 5740 upper partial denture 193 6059 abutment supported porcelain/high noble 633 5741 lower partial denture 193 6060 abutment supported porcelain/base metal 535 Laboratory Reline 6061 abutment supported porcelain/noble metal 633 5750 complete upper denture 220 6062 abutment supported high noble metal 645 5751 complete lower denture 220 6063 abutment supported cast metal 535 5760 upper partial denture 220 6064 abutment supported noble metal 645 5761 lower partial denture 220 6094 abutment supported titanium 580 Prosthetic Miscellaneous 6065 implant supported porcelain/ceramic 652 5850 tissue conditioning, maxillary 79 6066 implant supported porcelain/high noble metal 633 5851 tissue conditioning, mandibular 79 6067 implant supported high noble metal 645 5876 add metal substructure to acrylic full denture 79 6092 recement implant crown 71 5992 adjust prosthetic appliance 116 DENTURES 5993 maintenance & cleaning of prosthesis 50 5110 complete upper/maxillary 660 5120 complete lower/mandibular 660 5130 immediate upper/maxillary 750 5140 immediate lower/mandibular 750 5211 upper partial-acrylic base (includes clasps) 610 5212 lower partial-acrylic base (includes clasps) 610 5213 upper partial-cast metal framework 781 5214 lower partial-cast metal framework 781 5221 immediate upper/maxillary partial-resin base 564 5222 immediate lower/mandibular partial-resin base 564 5223 immediate upper/maxillary partial-metal frame 737 5224 immediate lower/mandibular partial-metal frame 737 5225 flexi maxillary partial denture 610 5226 flexi mandibular partial denture 610 Revised December 2018 Page 3 of 4
MAJOR CARE (Plan Spcific Benefits) IMPLANT (Only for Plans DN0,DN3 & DN5) Implant Lifetime maximum of $2,200 per individual. Patient must be eligible for six (6) consecutive months before Implant benefit can be used. 6010 /6011 6013 first and/or second stage of implant (per tooth) surgical placement mini Implant (per tooth) 1,100 550 IMPLANT PROCEDURES (Only for Plans DN0,DN3 & DN5 ) Part of the $1,200 prosthetic annual max DN0,DN5 Part of the $1,500 all inclusive max DN3 6110 implant/abutment complete remv-maxillary 1,000 6111 implant/abutment complete remv-mandibular 1,000 6112 implant/abutment partial remv-maxillary 500 6113 implant/abutment partial remv-mandibular 500 6114 implant/abutment complete fixed-maxillary 1,000 6115 implant/abutment complete fixed-mandibular 1,000 6116 implant/abutment partial fixed-maxillary 1,000 6117 implant/abutment partial fixed-mandibular 1,000 6055 implant connecting bar 305 6056 implant prefabricated abutment 311 6057 implant custom abutment 367 6096 remove broken implant retaining screw 50 6100 implant removal by report Revised December 2018 Page 4 of 4