Dental Expense Benefits

PPO Plans Prepaid (HMO) Plans
Plan Administrator CIGNA DPPO (Radius Network) United Concordia
Dental Plan Option High Medium Low
Annual Benefit Maximum $2,500 $1,500 $1,500 None
Dental Preferred Provider 100% 100% 80% Not Applicable
Preventive & Diagnostic Services
X-rays, Complete (including exam) $85.00 $53.90 $45.00 No charge
X-rays, First Periapical $25.00 $11.45 $14.00 No charge
X-rays, Next Periapical $12.oo $6.75 $5.00 No charge
X-rays, 2 Bitewings (including exam) $36.00 $19.10 $15.00 No charge
X-rays, 4 Bitewings (including exam) $47.00 $26.75 $20.00 No charge
Prophylaxis, Adult $61.00 $47.75 $30.00 No charge
Prophylaxis, Child $60.00 $38.20 $30.00 No charge
Restorative Services
Amalgam, 1 Surface $70.00 $43.55 $30.00 No charge
Amalgam, 2 Surfaces $85.00 $55.45 $40.00 No charge
Composite Resin, 1 Surface $100.00 $51.50 $40.00 No charge
Crown, Porcelain with Metal $650.00 $412.80 $300.00 $60.00 (plus cost of metal)
Other Services
Perio Scale $175.00 $99.00 $40.00 No charge
Simple Extraction $85.00 $43.55 $30.00 No charge
Orthodontia (Adults & Children) Refer to your Schedule of Benefits $1,500 for children up to age 19, plus start up fees. $2,000 for adults plus start up fees. 2-year maximum length of treatment; additional usual and customary charges thereafter.

Filing a Claim

If you use a network dentist, the dentist’s office will usually file the claim for you. If you use a non-network dentist, you will usually need to file a claim yourself. Call CIGNA Dental at 1-800-244-6224 to request a form. You should submit your claim within 90 days from the date you receive service.

You will need to provide:

  • The date or dates the service was rendered;
  • The nature of the treatment plan and the type of service or supply furnished; and
  • The name, address, and signature of the dentist who provided the services.

Mail your completed claim form to the following address:
United Concordia Dental Claims
PO Box 69421
Harrisburg, PA 17106-9421