Dental Fee Schedule
Below is the Dental Fee Schedule for all Allegiant Care 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 Allegiant Care pays. Allegiant Care 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:
- Allegiant Care’s Electronic Payer ID # is 38238, Group #: R40.
- Required documentation, including x–ray images, must be submitted on paper
- Periodontal work – full–mouth x–rays and charting
- Soft tissue grafts – a narrative statement and charting
- Bony impactions – a panorex x–ray
- Completed endodontic work – pre–op and post–op periapical x–rays
- Prosthetics – a pre–op periapical x–ray showing apex, narrative statement for
recommended crown; and x–ray of completed crown - Adult orthodontic treatment – x–rays and issue being corrected
- All wisdom teeth claims/estimates need to be submitted to Allegiant Care 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 contact us at 1–800–258–9732 Option 3.
