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Dental Benefits Program: Flagship NJ7 Plan — 2-50 Enrolled Employees Benefit Summary
Primary services are covered if necessary and performed by your attending Plan Dentist subject to the limitations of the group contract.
Frequently requested procedures and copays
| Procedure Code | Enrollee Copayments | |
| D0120 | Periodic oral evaluation — established patient — per 6-month period | $0 |
| D0210 | Intraoral — complete series of radiographic images — limited to 1 series every 24 months | $0 |
| D1110 | Prophylaxis cleaning — adult — 1 D1110, D1120 or D4346 per 6-month period | $0 |
| D1120 | Prophylaxis cleaning — child — 1 D1110, D1120 or D4346 per 6-month period | $0 |
| D1351 | Sealant — per tooth — limited to permanent molars through age 15 | $30 |
| D2140 | Amalgam — one surface, primary or permanent | $0 |
| D2330 | Resin-based composite — one surface, anterior | $0 |
| D2391 | Resin-based composite — one surface, posterior | $35 |
| D2740 | Crown — porcelain/ceramic substrate | $290 |
| D2791 | Crown — full cast predominantly base metal | $290 |
| D2952 | Post and core in addition to crown, indirectly fabricated — includes canal preparation | $200 |
| D3310 | Root canal — endodontic therapy, anterior tooth (excluding final restoration) | $185 |
| D3330 | Root canal — endodontic therapy, molar (excluding final restoration) | $285 |
| D4260 | Osseous surgery (including elevation of a full thickness flap and closure) — four or more contiguous teeth or tooth bounded spaces per quadrant | $275 |
| D4341 | Periodontal scaling and root planing — four or more teeth per quadrant — limited to 4 quadrants during any 12 consecutive months | $70 |
| D4910 | Periodontal maintenance — limited to 1 treatment each 6-month period | $50 |
| D5110 | Complete denture — maxillary | $300 |
| D5213 | Maxillary partial denture — cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | $340 |
| D7140 | Removal of impacted tooth — completely bony | $0 |
| Orthodontics (Adult & Child) | $3,200 | |
NJ regulation requires that each employer or other organization with 25 or more employees or members during the full preceding calendar year offer its employees or members the option of selecting alternate coverage which permits covered persons to obtain dental services from any dentist of their choice whenever the employer is contributing to a dental plan contract (as described in N.J.A.C. 11:10-2.2(a)).
Diagnostic
| Procedure Code | Enrollee Copayments | |
| D0120 | Periodic oral evaluation — established patient — per six-month period | $0 |
| D0140 | Limited oral evaluation — problem focused | $0 |
| D0145 | Oral evaluation for a patient under three years of age and counseling with primary caregiver | $0 |
| D0150 | Comprehensive oral evaluation — new or established patient | $0 |
| D0160 | Detailed and extensive oral evaluation — problem focused, by report | $0 |
| D0170 | Re-evaluation — limited, problem focused (established patient; not post-operative visit) | $0 |
| D0180 | Comprehensive periodontal evaluation — new or established patient | $0 |
| D0210 | Intraoral — complete series of radiographic images — limited to 1 series every 24 months | $0 |
| D0220 | Intraoral — periapical first radiographic image | $0 |
| D0230 | Intraoral — periapical each additional radiographic image | $0 |
| D0240 | Intraoral — occlusal radiographic image | $0 |
| D0260 | Extraoral — each additional film | $0 |
| D0270 | Bitewing — single radiographic image | $0 |
| D0272 | Bitewings — two radiographic images | $0 |
| D0273 | Bitewings — three radiographic images | $0 |
| D0274 | Bitewings — four radiographic images — limited to 1 series every 6 months | $0 |
| D0321 | Other temporomandibular joint films, by report | $0 |
| D0330 | Panoramic radiographic image | $0 |
| D0415 | Collection of microorganisms for culture and sensitivity | $0 |
| D0460 | Pulp vitality tests | $0 |
| D0470 | Diagnostic casts | $0 |
| D0601 | Caries risk assessment and documentation, with a finding of low risk — 1 every 3 years | $0 |
| D0602 | Caries risk assessment and documentation, with a finding of moderate risk — 1 every 3 years | $0 |
| D0603 | Caries risk assessment and documentation, with a finding of high risk — 1 every 3 years | $0 |
Preventive
| Procedure Code | Enrollee Copayments | |
| D1110 | Prophylaxis cleaning — adult — 1 D1110, D1120, or D4346 per six-month period | $0 |
| D1120 | Prophylaxis cleaning — child — 1 D1110, D1120, or D4346 per six-month period | $0 |
| D1208 | Topical application of fluoride — excluding varnish — child to age 19; 1 D1206 or D1208 per six-month period | $0 |
| D1330 | Oral hygiene instructions | $0 |
| D1351 | Sealant — per tooth — limited to permanent molars through age 15 | $30 |
| D1510 | Space maintainer — fixed — unilateral | $0 |
| D1515 | Space maintainer — fixed — bilateral | $0 |
| D1520 | Space maintainer — removable — unilateral | $0 |
| D1525 | Space maintainer — removable — bilateral | $0 |
| D1550 | Re-cement or re-bond space maintainer | $0 |
| D1555 | Removal of fixed space maintainer | $0 |
| D1575 | Distal shoe space maintainer — fixed — unilateral — child to age 9 | $0 |
Restorative
Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners, and acid etch procedures
Replacement of crowns, inlays, and onlays requires the existing restoration to be 5+ years old.
Extensive treatment plans involving 10 or more crowns or units of fixed bridgework (major mouth reconstruction) and all treatment associated with the reconstruction are not covered.
| Procedure Code | Enrollee Copayments | |
| Silver (Amalgam) Restorations — Primary/Permanent Teeth: | ||
| D2140 | Amalgam — one surface, primary or permanent | $0 |
| D2150 | Amalgam — two surfaces, primary or permanent | $0 |
| D2160 | Amalgam — three surfaces, primary or permanent | $0 |
| D2161 | Amalgam — four or more surfaces, primary or permanent | $0 |
| Resin (White) Restoration — Anterior/Posterior Teeth: | ||
| D2330 | Resin-based composite — one surface, anterior | $0 |
| D2331 | Resin-based composite — two surfaces, anterior | $0 |
| D2332 | Resin-based composite — three surfaces, anterior | $0 |
| D2335 | Resin-based composite — four or more surfaces or involving incisal angle (anterior) | $0 |
| D2390 | Resin-based composite crown, anterior | $100 |
| D2391 | Resin-based composite — one surface, posterior | $35 |
| D2392 | Resin-based composite — two surfaces, posterior | $40 |
| D2393 | Resin-based composite — three surfaces, posterior | $50 |
| D2394 | Resin-based composite — four or more surfaces, posterior | $75 |
| Inlay or Onlay Metallic: | ||
| D2510 | Inlay — metallic — one surface | Optional |
| D2520 | Inlay — metallic — two surfaces | Optional |
| D2530 | Inlay — metallic — three or more surfaces | Optional |
| D2542 | Onlay — metallic — two surfaces | $270 |
| D2543 | Onlay — metallic — three surfaces | $270 |
| D2544 | Onlay — metallic — four or more surfaces | $270 |
| Inlay or Onlay Porcelain/Ceramic: | ||
| D2610 | Inlay — porcelain/ceramic — one surface | Optional |
| D2620 | Inlay — porcelain/ceramic — two surfaces | Optional |
| D2630 | Inlay — porcelain/ceramic — three or more surfaces | Optional |
| D2642 | Onlay — porcelain/ceramic — two surfaces | Optional |
| D2643 | Onlay — porcelain/ceramic — three surfaces | Optional |
| D2644 | Onlay — porcelain/ceramic — four or more surfaces | Optional |
| Inlay or Onlay Resin-Based Composite: | ||
| D2650 | Inlay — resin-based composite — one surface | Optional |
| D2651 | Inlay — resin-based composite — two surfaces | Optional |
| D2652 | Inlay — resin-based composite — three or more surfaces | Optional |
| D2662 | Onlay — resin-based composite — two surfaces | Optional |
| D2663 | Onlay —resin-based composite — three surfaces | Optional |
| D2664 | Onlay — resin-based composite — four or more surfaces | Optional |
Crowns
Limitations may apply. Refer to your Benefit Plan Summary booklet.
| Procedure Code | Enrollee Copayments | |
| D2710 | Crown — resin-based composite (indirect) | $100 |
| D2712 | Crown — ¾ resin-based composite (indirect) | $270 |
| D2720 | Crown — resin with high noble metal* | $290 |
| D2721 | Crown — resin with predominantly base metal | $290 |
| D2722 | Crown — resin with noble metal* | $290 |
| D2740 | Crown — porcelain/ceramic substrate | $290 |
| D2750 | Crown — porcelain fused to high noble metal* | $290 |
| D2751 | Crown — porcelain fused to predominantly base metal | $290 |
| D2752 | Crown — porcelain fused to noble metal* | $290 |
| D2780 | Crown — ¾ cast high noble metal* | $270 |
| D2781 | Crown — ¾ cast predominantly base metal | $270 |
| D2782 | Crown — ¾ cast noble metal* | $270 |
| D2783 | Crown — ¾ porcelain/ceramic | $270 |
| D2790 | Crown — full cast high noble metal* | $290 |
| D2791 | Crown — full cast predominantly base metal | $290 |
| D2792 | Crown — full cast noble metal* | $290 |
| D2794 | Crown — titanium | Optional |
| D2910 | Re-cement or re-bond inlay, onlay, veneer, or partial coverage restoration | $0 |
| D2915 | Re-cement or re-bond indirectly fabricated or prefabricated post and core | $0 |
| D2920 | Re-cement or re-bond crown | $0 |
| D2921 | Reattachment of tooth fragment, incisal edge, or cusp (anterior) | $0 |
| D2929 | Prefabricated porcelain/ceramic crown — primary tooth — anterior | $125 |
| D2930 | Prefabricated stainless steel crown — primary tooth | $75 |
| D2931 | Prefabricated stainless steel crown — permanent tooth | $75 |
| D2932 | Prefabricated resin crown — anterior primary tooth | $100 |
| D2940 | Protective restoration | $0 |
| D2950 | Core buildup, including any pins when required | $0 |
| D2951 | Pin retention — per tooth, in addition to restoration | $27 |
| D2952 | Post and core in addition to crown, indirectly fabricated — includes canal preparation | $200 |
| D2953 | Each additional indirectly fabricated post — same tooth — includes canal preparation | $200 |
| D2954 | Prefabricated post and core in addition to crown — base metal post; includes canal preparation | $275 |
| D2957 | Each additional prefabricated post — same tooth — base metal post; includes canal preparation | $200 |
Endodontics
| Procedure Code | Enrollee Copayments | |
| D3110 | Pulp cap — direct (excluding final restoration) | $20 |
| D3120 | Pulp cap — indirect (excluding final restoration) | $20 |
| D3220 | Therapeutic pulpotomy (excluding final restoration) — removal of pulp coronal to the dentinocemental junction and application of medicament | $50 |
| D3221 | Pulpal debridement, primary, and permanent teeth | $50 |
| D3230 | Pulpal therapy (resorbable filling) — anterior, primary tooth (excluding final restoration) | $50 |
| D3240 | Pulpal therapy (resorbable filling) — posterior, primary tooth (excluding final restoration) | $50 |
| D3310 | Root canal — endodontic therapy, anterior tooth (excluding final restoration) | $185 |
| D3320 | Root canal — endodontic therapy, bicuspid tooth (excluding final restoration) | $225 |
| D3330 | Root canal — endodontic therapy, molar (excluding final restoration) | $285 |
| D3346 | Retreatment of previous root canal therapy — anterior | $200 |
| D3347 | Retreatment of previous root canal therapy — bicuspid | $260 |
| D3348 | Retreatment of previous root canal therapy — molar | $300 |
| D3410 | Apicoectomy — anterior | $150 |
| D3421 | Apicoectomy — bicuspid (first root) | $150 |
| D3425 | Apicoectomy — molar (first root) | $150 |
| D3426 | Apicoectomy (each additional root) | $100 |
| D3427 | Periradicular surgery without apicoectomy | $150 |
| D3430 | Retrograde filling — per root | $70 |
| D3450 | Root amputation — per root | $85 |
| D3920 | Hemisection (including any root removal), not including root canal therapy | $125 |
| Specialty services are covered if necessary by a plan dental specialist with a referral from your primary care dentist. Services are subject to the limitations and exclusions of the group contract. | ||
Periodontics
Includes preoperative and postoperative evaluations and treatment under a local anesthetic.
| Procedure Code | Enrollee Copayments | |
| D4210 | Gingivectomy or gingivoplasty — four or more contiguous teeth or tooth bounded spaces per quadrant | $125 |
| D4211 | Gingivectomy or gingivoplasty — one to three contiguous teeth or tooth bounded spaces per quadrant | $50 |
| D4212 | Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth | $25 |
| D4240 | Gingival flap procedure, including root planing — four or more contiguous teeth or tooth bounded spaces per quadrant | $135 |
| D4241 | Gingival flap procedure, including root planing — one to three contiguous teeth or tooth bounded spaces per quadrant | $80 |
| D4249 | Clinical crown lengthening — hard tissue | $125 |
| D4260 | Osseous surgery (including elevation of a full thickness flap and closure) — four or more contiguous teeth or tooth bounded spaces per quadrant | $275 |
| D4261 | Osseous surgery (including elevation of a full thickness flap and closure) — one to three contiguous teeth or tooth bounded spaces per quadrant | $180 |
| D4263 | Bone replacement graft — retained natural tooth — first site in quadrant | $150 |
| D4264 | Bone replacement graft — retained natural tooth — each additional site in quadrant | $150 |
| D4270 | Pedicle soft tissue graft procedure | $170 |
| D4277 | Free soft tissue graft procedure (including recipient and donor surgical sites), first tooth, implant, or edentulous tooth position in graft | $170 |
| D4278 | Free soft tissue graft procedure (including recipient and donor surgical sites), each additional contiguous tooth, implant, or edentulous tooth position in same graft site | $170 |
| D4341 | Periodontal scaling and root planing — four or more teeth per quadrant — limited to 4 quadrants during any 12 consecutive months | $70 |
| D4342 | Periodontal scaling and root planing — one to three teeth per quadrant — limited to 4 quadrants during any 12 consecutive months | $70 |
| D4346 | Scaling in presence of generalized moderate or severe gingival inflammation — full mouth, after oral evaluation — 1 D1110, D1120 or D4346 per six-month period | $0 |
| D4355 | Full mouth debridement to enable comprehensive evaluation and diagnosis — limited to 1 treatment in any 12 consecutive months | $70 |
| D4910 | Periodontal maintenance — limited to 1 treatment each six-month period | $50 |
Prosthodontics — Removable
For all listed dentures and partial dentures, co-payment includes after delivery adjustments and tissue conditioning, if needed, for the first six months after placement. The covered person must continue to be eligible, and the service must be provided at the Plan Dentist’s facility where the denture was originally delivered.
Rebases, relines, and tissue conditioning are limited to 1 per denture during any 12 consecutive months.
Replacement of a denture or a partial denture requires the existing denture to be 5+ years old.
| Procedure Code | Enrollee Copayments | |
| D5110 | Complete denture — maxillary | $300 |
| D5120 | Complete denture — mandibular | $300 |
| D5211 | Maxillary partial denture — resin base (including any conventional clasps, rests, and teeth) | $320 |
| D5212 | Mandibular partial denture — resin base (including any conventional clasps, rests, and teeth) | $320 |
| D5213 | Maxillary partial denture — cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) | $340 |
| D5214 | Mandibular partial denture — cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) |
$340 |
| D5410 | Adjust complete denture — maxillary | $0 |
| D5411 | Adjust complete denture — mandibular | $0 |
| D5421 | Adjust partial denture — maxillary | $0 |
| D5422 | Adjust partial denture — mandibular | $0 |
| D5511 | Repair broken complete denture base, mandibular | $50 |
| D5512 | Repair broken complete denture base, maxillary | $50 |
| D5520 | Replace missing or broken teeth — complete denture (each tooth) | $60 |
| D5611 | Repair resin partial denture base, mandibular | $50 |
| D5612 | Repair resin partial denture base, maxillary | $50 |
| D5621 | Repair cast partial framework, mandibular | $60 |
| D5622 | Repair cast partial framework, maxillary | $60 |
| D5630 | Repair or replace broken clasp per tooth | $60 |
| D5640 | Replace broken teeth — per tooth | $60 |
| D5650 | Add tooth to existing partial denture | $70 |
| D5660 | Add clasp to existing partial denture per tooth |
$70 |
| D5670 | Replace all teeth and acrylic on cast metal framework (maxillary) | $225 |
| D5671 | Replace all teeth and acrylic on cast metal framework (mandibular) | $225 |
| D5730 | Reline complete maxillary denture (chairside) | $75 |
| D5731 | Reline complete mandibular denture (chairside) | $75 |
| D5740 | Reline maxillary partial denture (chairside) | $75 |
| D5741 | Reline mandibular partial denture (chairside) | $75 |
| D5750 | Reline complete maxillary denture (laboratory) | $110 |
| D5751 | Reline complete mandibular denture (laboratory) | $110 |
| D5760 | Reline maxillary partial denture (laboratory) | $110 |
| D5761 | Reline mandibular partial denture (laboratory) | $110 |
Prosthodontics — Fixed
Each retainer and pontic constitutes a unit in a fixed partial denture (bridge).
Replacement of a crown, pontic, inlay, onlay, or stress breaker requires the existing bridge to be 5+ years old.
Extensive treatment plans involving 10 or more crowns or units of fixed bridgework (major mouth reconstruction) and all treatment associated with the reconstruction are not covered.
| Procedure Code | Enrollee Copayments | |
| D6210 | Pontic cast high noble metal* | $290 |
| D6211 | Pontic cast predominantly base metal | $290 |
| D6212 | Pontic cast noble metal* | $290 |
| D6240 | Pontic porcelain fused to high noble* | $290 |
| D6241 | Pontic — porcelain fused to predominantly base metal | $290 |
| D6242 | Pontic porcelain fused to noble metal* |
$290 |
| D6245 | Pontic porcelain/ceramic | $200 |
| D6250 | Pontic resin w/high noble metal* | $290 |
| D6251 | Pontic resin w/predominately base metal | $290 |
| D6252 | Pontic resin with noble metal* | $290 |
| D6610 | Retainer onlay — cast high noble metal, two surfaces* | $270 |
| D6611 | Retainer onlay — cast high noble metal, three or more surfaces* | $270 |
| D6612 | Retainer onlay — cast predominantly base metal, two surfaces | $270 |
| D6613 | Retainer onlay — cast predominantly base metal, three or more surfaces | $270 |
| D6614 | Retainer onlay — cast noble metal, two surfaces* | $270 |
| D6615 | Retainer onlay — cast noble metal, three or more surfaces* | $270 |
| D6720 | Retainer crown — resin with high noble metal* | $290 |
| D6721 | Retainer crown — resin with predominantly base metal | $290 |
| D6722 | Retainer crown — resin with noble metal* | $290 |
| D6740 | Retainer crown — porcelain/ceramic | $290 |
| D6750 | Retainer crown — porcelain fused to high noble metal* | $290 |
| D6751 | Retainer crown — porcelain fused to predominantly base metal | $290 |
| D6752 | Retainer crown — porcelain fused to noble metal* | $290 |
| D6780 | Retainer crown — ¾ cast high noble metal* | $270 |
| D6781 | Retainer crown — ¾ cast predominantly base metal | $270 |
| D6782 | Retainer crown — ¾ cast noble metal* | $270 |
| D6790 | Retainer crown — full cast high noble metal* | $290 |
| D6791 | Retainer crown — full cast predominantly base metal | $290 |
| D6792 | Retainer crown — full cast noble metal* | $290 |
| D6930 | Re-cement or re-bond fixed partial denture | $0 |
| *Note: Base metal is the benefit. Noble and high noble metal (precious), if used, will be charged to the Enrollee at the additional laboratory cost of the high noble metal. This applies to crowns, bridges, cast post and cores, inlays, and onlays. Porcelain on molars is considered optional treatment. | ||
Oral and Maxillofacial Surgery
Includes preoperative and postoperative evaluations and treatment under a local anesthetic.
| Procedure Code | Enrollee Copayments | |
| D7111 | Extraction, coronal remnants — primary tooth | $0 |
| D7140 | Extraction, erupted tooth or exposed root (elevation and/or forceps removal) | $0 |
| D7210 | Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated | $0 |
| D7220 | Removal of impacted tooth — soft tissue | $0 |
| D7230 | Removal of impacted tooth — partially bony | $0 |
| D7240 | Removal of impacted tooth — completely bony | $0 |
| D7241 | Removal of impacted tooth — completely bony, with unusual surgical complications | $0 |
| D7250 | Removal of residual tooth roots (cutting procedure) | $0 |
| D7280 | Exposure of an unerupted tooth | $0 |
| D7283 | Placement of device to facilitate eruption of impacted tooth | $0 |
| D7286 | Incisional biopsy of oral tissue — soft — does not include pathology laboratory procedures | $0 |
| D7310 | Alveoloplasty in conjunction with extractions — four or more teeth or tooth spaces, per quadrant | $0 |
| D7311 | Alveoloplasty in conjunction with extractions — one to three teeth or tooth spaces, per quadrant | $0 |
| D7320 | Alveoloplasty not in conjunction with extractions — four or more teeth or tooth spaces, per quadrant | $0 |
| D7321 | Alveoloplasty not in conjunction with extractions — one to three teeth or tooth spaces, per quadrant | $0 |
| D7340 | Vestibuloplasty — ridge extension (secondary epithelialization) | $0 |
| D7350 | Vestibuloplasty — ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment, and management of hypertrophied and hyperplastic tissue) | $0 |
| D7410 | Excision of benign lesion up to 1.25 cm | $0 |
| D7411 | Excision of benign lesion greater than 1.25 cm | $0 |
| D7440 | Excision of malignant tumor up to 1.25 cm | $0 |
| D7441 | Excision of malignant tumor greater than 1.25 cm | $0 |
| D7450 | Removal of benign odontogenic cyst or tumor — lesion diameter up to 1.25 cm | $0 |
| D7451 | Removal of benign odontogenic cyst or tumor — lesion diameter greater than 1.25 cm | $0 |
| D7460 | Removal of nonodontogenic cyst or tumor lesion diameter up to 1.25 cm | $0 |
| D7461 | Removal of nonodontogenic cyst or tumor lesion diameter greater than 1.25 cm | $0 |
| D7465 | Destruction of lesion(s) by physical or chemical method, by report | $0 |
| D7471 | Removal of lateral exostosis (maxilla or mandible) | $0 |
| D7472 | Removal of torus palatinus | $0 |
| D7473 | Removal of torus mandibularis | $0 |
| D7485 | Surgical reduction of osseous tuberosity | $0 |
| D7510 | Incision and drainage of abscess — intraoral soft tissue | $0 |
| D7511 | Incision and drainage of abscess — intraoral soft tissue — complicated (includes drainage of multiple fascial spaces) | $0 |
| D7520 | Incision and drainage of abscess extraoral soft tissue | $0 |
| D7521 | Incision and drainage of abscess extraoral soft tissue — complicated (includes drainage of multiple fascial spaces) | $0 |
| D7530 | Removal of foreign bodies | $0 |
| D7540 | Removal of reaction bodies | $0 |
| D7550 | Removal of non-vital bone partial ostectomy/sequestrectomy | $0 |
| D7960 | Frenulectomy — also known as frenectomy or frenotomy — separate procedure not incidental to another procedure | $0 |
| D7963 | Frenuloplasty | $0 |
| D7970 | Excision of hyperplastic tissue — per arch | $0 |
| D7971 | Excision of pericoronal gingiva | $0 |
Orthodontics
The listed co-payment for each phase of orthodontic treatment (limited, interceptive, or comprehensive) covers up to 24 months of active treatment. Beyond 24 months, an additional monthly fee may apply.
| Procedure Code | Enrollee Copayments | |
| Orthodontic treatment under age 19 |
$3,200 | |
| Orthodontic treatment over age 19 | $3,200 | |
Adjunctive General Services
| Procedure Code | Enrollee Copayments | |
| D9110 | Palliative (emergency) treatment of dental pain — minor procedure | $0 |
| D9211 | Regional block anesthesia | $0 |
| D9212 | Trigeminal division block anesthesia | $0 |
| D9215 | Local anesthesia in conjunction with operative or surgical procedures | $0 |
| D9222 | Deep sedation/general anesthesia — first 15 minutes | $0 |
| D9223 | Deep sedation/general anesthesia — each 15-minute increment | $0 |
| D9239 | Intravenous moderate (conscious) sedation/analgesia — first 15 minutes | $0 |
| D9243 | Intravenous moderate (conscious) sedation/analgesia — each 15-minute increment | $0 |
| D9310 | Consultation — diagnostic service provided by dentist or physician other than requesting dentist or physician | $0 |
| D9430 | Office visit for observation (during regularly scheduled hours) — no other services performed | $0 |
| D9440 | Office visit — after regularly scheduled hours | $0 |
| D9450 | Case presentation, detailed and extensive treatment planning | $0 |
| D9986 | Missed appointment (failure to cancel appointment 24 hours prior notification) | $10 per 15 minutes |
| D9987 | Cancelled appointment (failure to cancel appointment 24 hours prior notification) | $10 per 15 minutes |
Out-of-Area Emergency
| Flagship will reimburse the enrollee for actual charges less any applicable copayment, up to $100 per enrollee when receiving emergency care while temporarily more than 35 miles from the attending primary care dental office. Services that are more expensive than the treatment usually provided under accepted dental practice standards are considered optional treatment. The patient must pay the difference in cost between the dentist’s usual fees for the covered benefit and the optional or more expensive treatment plus any applicable copayment. All services are subject to the limitations and exclusions outlined in your Dental Benefit |
Delta Dental of New Jersey is a part of Delta Dental Plans Association. Through our national network of Delta Dental companies, we offer dental coverage in all 50 states, Puerto Rico and other U.S. territories.
