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Maximum Reimbursement for Dental Services 2021 MAXIMUM REIMBURSEMENT FOR DENTAL SERVICES 2021 PLANS: CIGNA SALUD DENTAL MIXTO Outside the Cigna Dental Network, the insured will be reimbursed according to the plan contracted, as indicated in the particular conditions of the policy. The amount to be reimbursed will never exceed the following maximum limits for each of the services, and will be calculated according to the reimbursement percentage and the insured amount contracted. B ZONE Aragón, Cataluña, Islas Baleares, La Rioja, Madrid, Navarra y País Vasco 0.- ORAL DIAGNOSIS 1560 Lumineers®daVinci® ultra-slim veneer (not carved) € 449 0110 Initial oral examination and diagnosis € 30 PERIORAL AESTHETICS 0120 Quote € 30 1610 Facial mesotherapy (per session) € 138 0130 Emergency examination (during consultation hours) € 30 1620 Hyaluronic acid filling for nasogenian furrows (per session) € 322 0140 Professional assessment € 30 1625 Hyaluronic acid filling for marionette lines (per session) € 322 0150 Checkup € 20 1630 Hyaluronic acid filling for lips (per vial) € 322 Nocturnal, weekend and holiday emergencies. 1635 Hyaluronic acid filling for nasolabial furrows (per session) € 368 0190 € 100 Only at authorized network clinics (Tel. 902 040 344) Hyaluronic acid filling for nasogenian furrows + marionette lines + lip 1640 € 426 RADIOGRAPHS (per session) 0210 Periapical X-Rays € 10 0212 Occlusal X-Rays € 13 2.- DENTAL RESTORATION 2105 Provisional obturation / Filling 0214 Bitewing X-Rays € 12 € 25 2110 Amalgam (1 surface) 0220 Orthopantomography € 40 € 43 0222 Lateral X-Rays (Teleradiography) € 40 2120 Amalgam (2 surfaces) € 50 0224 X-Rays of the tempomandibular joint € 50 2130 Complex amalgam (reconstruction) € 62 0250 Periodontal X-Rays € 60 2140 Major restoration with dowels and/or pins (cores) € 81 0310 CT scan / Dentascan (one jaw) € 115 2145 Major restoration with fiber or carbon post € 94 0312 CT scan / Dentascan (both jaws) € 150 2147 Direct pulp capping € 7 0314 CT scan / Dentascan (sector) € 81 2150 Fitting pins € 12 COMPLEMENTARY EXAMINATIONS 2152 Fitting of intraradicular post or cast post and core € 12 0410 Study models € 24 2155 Direct preprosthetic post impression € 7 0415 Waxing diagnosis (per tooth) € 12 2160 Cosmetic dentistry ugly irregularities (incisor remodelling, etc.) € 7 0420 Diagnostic photography € 40 2165 Amalgam polishing € 7 0430 Cephalometrics € 50 2190 Extra for laser decay treatment € 34 0440 Biopsy (sampling) € 55 INLAYS 0450 Microbiological test / biochemical studies (sampling) € 15 2205 Metal inlay € 88 0460 Blood collection for distinct profiles € 40 2210 Noble metal inlay € 175 AESTHETIC SMILE DESIGN 2220 Porcelain inlay € 186 Study and planning for digital recreation (includes photographs and / 2225 CAD/CAM inlay € 330 0510 € 58 or videos) 2230 Composite inlay € 125 0520 Data intake with intraoral scanner € 58 2240 Recement inlay € 27 0530 Biomodel € 46 PEDIATRIC DENTISTRY (children up to age 14 included) Deciduous dentition 0550 Mock up / Model / Aesthetic test (per piece) € 104 2410 Amalgam (filling) € 40 IMPLANT STUDY & MAINTENANCE 2412 Restoration € 53 Clinical examination, orthopantomography with markers, models, 0700 € 155 photography and radiological-surgical splint 2414 Temporary filling in deciduous teeth € 24 0710 Basic periodic maintenance € 40 2420 Stainless steel preformed crown € 68 Full annual maintenance: bougienage, prophylaxis, disassembly and 2430 Indirect pulp capping € 25 0720 € 108 polishing of prostheses, radiographs and retraining on oral hygiene 2432 Pulpotomy € 46 0750 Planning 3D models without surgical splints (scanner not included) € 190 2434 Root-end barrier formation (per visit) € 50 1.- PREVENTIVE AND COSMETIC 2436 Pulp incision and drainage (emergency treatment) € 32 1110 Prophylaxis (annual teeth cleaning) € 50 2440 Extraction, deciduous tooth € 15 1111 Second Periodontal Scaling and successive (oral cleaning) € 28 2450 Gingival surgery (per tooth) € 41 Tooth polishing (fluoride paste) 1115 € 10 PEDIATRIC DENTISTRY (children up to age 14 included) Permanent dentition 1117 Use of bicarbonate (difficult stains) € 10 2310 Sealing of pits and fissures (permanent molars) € 19 1120 Training on Oral hygiene € 10 2410 Amalgam (filling) € 37 1130 Training on Oral brushing technique € 10 2412 Restoration € 50 1140 Diet plan for decay control € 10 2420 Stainless steel preformed crown € 60 1150 Staining and plaque index € 10 2430 Indirect pulp capping € 24 1210 Topical application of fluoride, per session (twice a year) € 17 2432 Pulpotomy € 40 1310 Sealing of pits and fissures (permanent molars) € 21 2434 Root-end barrier formation (per visit) € 43 1410 Desensitising sealing (hypersensitivity treatment) € 27 2436 Pulp incision and drainage (emergency treatment) € 30 * Does not include the cleaning of removable prosthesis or implants Gingival surgery (per tooth) DENTAL AESTHETICS 2450 € 35 1510 Whitening of vital teeth (per arch) € 240 SPACE MAINTAINERS 1515 Plasma or laser light whitening (per arch) € 425 2510 Fixed, unilateral type € 140 1520 Whitening of non vital tooth (per session) € 40 2520 Removable, acrylic € 134 1530 Composite veneer € 85 2550 Recementing € 25 1535 Porcelain veneer € 290 3.- ENDODONTICS 1540 Aesthetic lithium disilicate veneer € 403 PULPECTOMY: (including 3500 and necessary X-rays) 3305 Supplement for mechanized root canals with rotary instruments € 40 1550 E. max® pressed porcelain veneer € 426 T.D.B. vs. 1020 ENG 1020 vs. T.D.B. Customer Service 91 418 40 40 - 93 301 06 56 | www.cigna.es € 3306 Supplement for root canals performed under microscope € 27 5185 Noble metal/titanium crown or bridge € 370 3310 Root canal (1 canal) (X-rays included) € 104 5210 Maryland Bridge € 406 3320 Root canal (2 canals) (X-rays included) € 131 5230 Bridge support or onlay € 48 3330 Root canal (3 or more canals) (X-rays included) € 164 5310 Cast metal stump, one root € 98 3315 Retreatment 1 canal (X-rays included) € 119 5330 Cast metal stump, more than one root € 113 3325 Retreatment 2 canals (X-rays included) € 152 5335 Cast noble metal stump € 127 3335 Retreatment 3 canals (X-rays included) € 188 5410 Recement crowns € 27 3350 Apex-formation with MTA (1 session) € 44 5415 Mechanical bridge dismantling € 27 ENDODONTRIC SURGERY 5420 Porcelain fixture € 67 3410 Periapical surgery (apicoectomy) € 155 REMOVABLE PROSTHESIS 3420 Retro filling (for root) € 50 5510 Complete acrylic (upper or lower) € 370 3440 Root amputation (hemisection) € 148 5520 Partial acrylic (1 to 3 teeth) € 170 3500 Pulp incision and drainage (Emergency treatment) € 34 5522 Partial acrylic (4 to 6 teeth) € 245 4.- PERIODONTICS 5525 Partial acrylic (7 or more teeth) € 329 4010 Periodontal evaluation (sounding) € 55 5528 Supplement for hypoallergenic or appropriate resin € 50 4020 Local chemotherapy application € 12 5529 Supplement for porcelain teeth (per tooth) € 18 4030 Occlusal examination € 20 5540 Partial flexible (Valplast or Flexite...) (1 to 3 teeth) € 460 4035 Occlusal adjustment by balancing / selective grinding € 30 5542 Parcial flexible (Valplast or Flexite...) (4 to 6 teeth) € 494 4110 Scaling and root planing (per quadrant) € 60 5546 Parcial flexible (Valplast or Flexite...) (7 or more teeth) € 533 4120 Periodontal treatment maintenance (throughout the mouth) € 35 5560 Neobase to rebase up to 5 dental pieces € 96 Decontamination of periodontal pockets and / or peri implantitis using 4130 € 32 5565 Neobase to rebase more than 5 dental pieces € 184 glycerin or ozone Restoration or addition of dental pieces of flexible Removable Partial 5570 € 89 4132 Treatment of periodontal pockets with Ligosan® doxycycline gel € 113 Prosthesis 4210 Gingivectomy or gingivoplasty (per tooth) € 35 Skeletal partial dentures (1 to 3 teeth) (it includes braces, plates, 5630 € 400 retainers / hooks…) 4220 Gingivectomy or gingivoplasty (per sextant) € 58 Skeletal partial dentures (4 to 6 teeth) (it includes braces, plates, 4230 Gingivectomy or gingivoplasty (per quadrant) € 66 5632 € 480 retainers / hooks…) 4290 Clinical crown extension (hard tissue) € 70 Skeletal partial dentures (7 to 9 teeth) (it includes braces, plates, 5634 € 540 4310 Periodontal surgery (surgical curettage per piece) € 22 retainers / hooks…) Periodontal flap surgery (per sextant) Skeletal partial dentures (10 or more teeth) (it includes braces, plates, 4320 € 110 5636 € 600 retainers / hooks…) 4330 Periodontal flap surgery (per quadrant) € 150 COMPOSITE PROSTHESES 4350 Modified Widman flap procedure (per quadrant) € 200 5710 Simple precision attachment € 148 4410 Flap surgery with graft (per piece) € 39 5715 Complex precision attachment € 182 4420 Flap surgery with graft (per sextant) € 177 5720 Telescopic crown € 128 Flap surgery with graft (per quadrant) 4430 € 243 5730 Retention bar € 216 Free mucosal or connective graft 4450 € 255 5740 Retention magnets € 175 4510 Periodontal splinting per piece € 31 IMPLANT PROSTHETICS 4520 Periodontal splinting (sector) € 131 5810 Transepithelial abutment € 192 4550 Peridontogram € 83 5815 Angle or cosmetic abutment € 230 4590 Laser treatment (per session) € 97 5816 Zirconium abutment € 243 REGENERATIVE THERAPY - BONE GRAFTING 5817 LOCATOR® type anchor € 281 Regenerative Membrane 4710 € 263 5820 Provisional crown on implant € 140 Titanium mesh 4740 € 283 5830 Noble metal / titanium crown or bridge € 421 Plasma rich in growth factors (P.R.G.F.) 4770 € 283 5840 Dental crown or bridge unit in zirconia (CAD/CAM) € 498 Alveoloplasty or bone filling (biomaterials) 4810 € 216 5850 Ball attachment (0-Ring, Dal-Ro, among others) € 255 Jaw remodelling
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