Dental Insurance—Cigna DHMO
Following is a sample schedule of the Cigna DHMO patient charge schedule:
CODE
PROCEDURE
PATIENT PAYS
Facts and tips
D1110
Adult Cleaning
No Charge
D0270
Bitewings
No Charge
◼ You are responsible for a $5 office visit fee per patient, per office visit. ◼ You have to be on the dentist ’ s roster in order to receive treatment. ◼ Check the Patient Charge Schedule K1 - V9 before receiving services to know your responsibility.
D0330
Panoramic X - Ray
No Charge
D2330
Composite - Surface
No Charge
D2140
Amalgam - 1 surface
No Charge
D2752
Crown - Porcelain
$425
D6794
Crown - Titanium
$460
◼ The Patient Charge Schedule K1 - V9 is located
D3310
Root Canal - Anterior
$210
in the EMB Resource page, or you can contact the Business Office for a copy.
D3320
Root Canal - Bicuspid
$245
D3330
Root Canal - Molar
$335
◼ If a procedure is not shown in the schedule, it is not covered .
D4210
Gingivectomy 4 per Quad
$180
D5110
Full Upper Denture
$625
D5120
Full Lower Denture
$625
Implant supported porcelain/ ceramic crown
D6065
$790
Monthly Dental Employee Cost
Ortho
24 - Month Treatment Fee
$2,040
Allotment Balance
Coverage Type
($ 14.38 )
Employee
$0
The amounts shown are the employee share of premium after the district $ 41.72 monthly dental benefit allotment.
$ 6.19 $ 8.98 $ 35.12
Employee & Spouse
$0
Employee & Child(ren)
$0
Employees cannot opt out of a dental or vision plan.
Employee & Family
$0
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