Patient Charge Schedules

Use these patient charge schedules to determine the amount to collect from your Cigna patients for certain coded dental procedures. Several plan sponsors (employers) are represented.
Document Title Document Type Document Size Last Updated
Patient Charge Schedules
Introduction Online Resource -- 07/06/2016
05 Series PDF 560kb 07/01/2013
06 Standard Copays Series PDF 560kb 07/01/2013
07 C Series PDF 606kb 07/01/2013
07 Preventive Care Series PDF 482kb 07/01/2013
07 Split Copay Series PDF 648kb 07/01/2013
07 Standard Copays Series PDF 649kb 07/01/2013
07 Value Plan A Alt Benefit Series PDF 568kb 07/01/2013
07 Value Plan Alt Benefit Series PDF 590kb 07/01/2013
07 Value Plan Specialty Access Series PDF 672kb 07/01/2013
08 C Series PDF 585kb 07/01/2013
08 Preventive Care Series PDF 573kb 07/01/2013
08 Split Copay Series PDF 603kb 07/01/2013
08 Standard Copay Series PDF 616kb 07/01/2013
08 Value Plan A Alt Benefit Series PDF 598kb 07/01/2013
08 Value Plan Alt Benefit Series PDF 629kb 07/01/2013
08 Value Plan Specialty Access Series PDF 627kb 07/01/2013
08 X Public Sector Lab Fee Charges Series PDF 625kb 03/01/2014
08 X Lab Fee Charges Series PDF 609kb 03/01/2014
09 C Series Revised 10/1/13 PDF 546kb 10/01/2013
09 Standard Copay Series PDF 590kb 08/27/2013
09 Value Plan A Alt Benefit Series PDF 281kb 08/27/2013
09 Value Plan Alt Benefit Series PDF 302kb 08/27/2013
09 Value Plan Specialty Access Series PDF 576kb 03/01/2014
09 X Lab Fee Charges Series PDF 362kb 08/27/2013
09 X Public Sector Lab Fee Charges Series PDF 796kb 06/25/2015
Aldine Independent School District Series RIXV9 PDF 388kb 01/19/2017
Aldine Independent School District Series RSXV9 PDF 189kb 01/19/2017
Arizona Medicare Comprehensive--MK1V9 PDF 579kb 11/09/2020
Arizona Medicare Preventive--MK2V9 PDF 531kb 11/09/2020
AT&T NS Series PDF 458kb 02/28/2017
Arizona State Retirement System W1-V9 AZ PDF 178kB 09/22/2020
Baxter NB/BC Series PDF 136kb 01/19/2017
County of San Bernardino BE Series PDF 603kb 07/01/2013
County of Maricopa MCSV7 Series PDF 206kb 07/01/2013
Honeywell NH Series PDF 205kB 02/25/2016
Honeywell NH208 PDF 313kB 03/11/2015
Houston Independent School District HIXV9 PDF 296kb 01/19/2017
IBM07 Series PDF 529kb 07/01/2013
McKesson L1I09 Series PDF 161kB 01/19/2017
MTA109 - Metropolitan Transit Authority (MTA) PDF 107kB 09/22/2020
Orlando Health OH Series PDF 564kb 07/01/2013
P Series Public Sector Alt Benefit PDF 212kb 01/19/2017
Pinellas County PSX09 Series PDF 141kb 07/11/2017
Prudential QPAI9 Series PDF 232kb 01/19/2017
Southeastern Pennsylvania Transit Authority PTA15 Series PDF 528kb 01/19/2017
Q Series Coinsurance PDF 876kb 08/27/2013
R04 Series PDF 557kb 07/01/2013
Shire NB/BC Series PDF 193kb 01/19/2017
State of Connecticut SCIO9 PDF 186kb 05/31/2019
State of Connecticut SCTI9 Series PDF 176kb 06/09/2016
State of Georgia SG-09 Series PDF 144kB 01/19/2017
State of New Jersey NJAY Series PDF 251kb 01/19/2017
State of New Jersey SNJ10 Series PDF 193kb 01/19/2017
State of Oklahoma OKIV9 Series PDF 193kb 01/19/2017
State of Tennessee Series T2IV9 Benefits-At-A-Glance for General Dentists (This version applies ONLY to members residing in TN) PDF 391kb 02/23/2021
State of Tennessee Series T2IV9 Benefits-At-A-Glance for Specialists (This version applies ONLY to members residing in TN) PDF 389kb 02/23/2021
State of Tennessee Series T2XV9 for General Dentists PDF 279kB 03/20/2019
State of Tennessee Series T2XV9 for Specialists PDF 280kB 03/20/2019
State of Tennessee Series T2XV9 for General Dentists in AZ PDF 295kB 03/20/2019
State of Tennessee Series T2XV9 for Specialists in AZ PDF 242kB 03/20/2019
YP Holdings NY Series PDF 159kB 01/01/2015
Appeal Process PDF 537kB 09/21/2011
Document Title Document Type Document Size Last Updated
Supporting Materials
Alternate Benefit Provision Online Resource -- 01/01/2015
Coinsurance Plans FAQs Online Resource -- --
Alternate Benefit Provision Plans PDF 35kb 01/01/2015
Most Commonly Performed Procedure Code Comparison Cigna Dental Care (01-08) 2020 PDF 234kb 12/18/2019
Most Commonly Performed Procedure Code Comparison Cigna Dental Care (01-08) 2021 PDF 1.17mb 10/28/2020
Most Commonly Performed Procedure Code Comparison Cigna Dental Care (09) 2020 PDF 184kb 12/18/2019
Most Commonly Performed Procedure Code Comparison Cigna Dental Care (09) 2021 PDF 768kb 10/28/2020
CDT 2020 - Cigna Dental Care® and DPPO PDF 169kb 11/20/2019
Document Title Document Type Document Size Last Updated
Copayment Basis Schedules
AT&T Copayment Basis Schedules (CBSs) Online Resource -- 12/25/2017
Baxter Copayment Basis Schedules (CBSs) Online Resource -- 03/14/2014
Honeywell Copayment Basis Schedules (CBSs) Online Resource -- 03/14/2014
YP Holdings Copayment Basis Schedules (CBSs) Online Resource -- 03/14/2014