SearchSite MapContact Us
Banner Home Page
Current Location: Home > Flagship >
Flagship
 

Description of DeltaCare Benefits and Patient Copayments

PRIMARY BENEFITS
PLAN G

Flagship provides benefits and requires a copayment, where noted, for the following services:

 

COVERED PERSON

PAYS

VISITS AND DIAGNOSTIC

 

Oral examination/office visit

Emergency treatment (palliative)

Specialist consultation

Pulp tests

N/C

N/C

N/C

N/C

PROPHYLAXIS AND FLUORIDE TREATMENT

 

Prophylaxis - 2 treatments per any 12 month period

Topical fluoride - to age 19 only

N/C

N/C

X-RAYS

 

Full mouth x-rays or Panorex - every 3 years

Single x-ray

Each additional x-ray up to and including 13 films

Bitewing x-rays - not more than 1 series of 4 films in any 6 month period

Intra-oral, occlusal view, upper or lower jaw

N/C

N/C

N/C

N/C

N/C

ORAL SURGERY

 

Extractions (uncomplicated) - local anesthetic

Surgical extractions

Post operative visits (sutures)

Local anesthetics

Removal of tooth (soft tissue)

Removal of tooth (partially bony)

Removal of tooth (completely bony)

N/C

N/C

N/C

N/C

N/C

N/C

N/C

PERIODONTICS

 

Emergency treatment (gum abscess, acute gum inflammation, etc.)

Subgingival curettage, per quadrant

Soft tissue surgery, per quadrant

Soft tissue surgery, per tooth (if fewer than 6 teeth)

Scaling and root planing (entire mouth)

Scaling and root planing (per quadrant)

Preventive Periodontal Procedures

Osseous Surgery (per quadrant)

N/C

$30

$90

$30

$40

$35

$30

$210

ENDODONTICS

 

Root amputation

Pulp capping

Pulpotomy

Vital pulpotomy

Temporary filling

Single root canal

Bi-root canal

Tri-root canal

Apicoectomy and filling canal

Apicoectomy on separate appointment

$70

$12

$30

$30

$85

$125

$150

$200

$115

$100




 

COVERED PERSON

PAYS

RESTORATIVE DENTISTRY

 

Silver restorations - Primary Teeth

Cavities involving 1 tooth surface

Cavities involving 2 tooth surfaces

Cavities involving 3 or more tooth surfaces

Silver restorations - Permanent Teeth

Cavities involving 1 tooth surface

Cavities involving 2 tooth surfaces

Cavities involving 3 or more tooth surfaces

Acrylic, Plastic Restorations

Acrylic or plastic filling

Silicate cement filling

Crowns (Caps)

Acrylic

Acrylic with metal

Porcelain

Porcelain with metal

Full metal crown

Gold onlay or 3/4 crown

Stainless steel (primary)

Stainless steel (permanent)

Removable acrylic space maintainer

Fixed spacer, band type

N/C

N/C

N/C

N/C

N/C

N/C

N/C

N/C

$75

$230

$220

$240

$240

$230

$50

$50

N/C

N/C

PROSTHETICS (Including Fixed Bridges)

 

Artifical Tooth Replacement

Tru-pontic type

Porcelain to metal

Plastic processed to gold

Dentures

Complete upper denture

Complete lower denture

Partial upper/lower (each)

Denture and partial adjustments

Denture and partial repairs

Adding teeth to existing partial or denture

Office reline

Laboratory reline

Recementation

Inlay

Crown

Bridge

$240

$240

$230

$250

$270

$270

N/C

$20

$30

$55

$75

N/C

N/C

N/C

OTHER PROCEDURES

 

Failure to cancel appointment (24 hours prior notification)

Emergency visit after normal visiting hours

$25

$25

   
   N/C = No Charge

 

Description of Benefits and Patient Copayments

SPECIALTY SERVICES
PLAN G

Flagship provides benefits and requires a copayment, where noted, for the following specialty services:

 

COVERED PERSON

PAYS

PERIODONTICS

 

Periodontal scaling (entire mouth)

Bone surgery

Bone graft

Bone grafts - multiple sites

Pedicle soft tissue grafts

Free soft tissue grafts

Periodontal scaling (per quadrant)

$125

$210

$100

$110

$115

$120

$35

ORAL SURGERY

 

Impaction - full bony

Root recovery

Closure of oral fistula

Surgical exposure of impacted or unerupted tooth for ortho reasons

Surgical exposure of impacted or unerupted tooth

Biopsy of oral tissue - hard

Biopsy of oral tissue - soft

Vestibuloplasty, per arch - uncomplicated

Vestibuloplasty, per arch - complicated

Excision of tumors - benign - lesion diameter up to 1.25 cm

Excision of tumors - benign - lesion diameter over 1.25 cm

Excision of tumors - malignant - lesion diameter up to 1.25 cm

Excision of tumors - malignant - lesion diameter over 1.25 cm

N/C

N/C

N/C

N/C

N/C

N/C

N/C

N/C

N/C

N/C

N/C

N/C

N/C

REMOVAL OF CYSTS AND NEOPLASM

 

Removal of odontogenic cyst or tumor up to 1.25 cm in diameter

Removal of odontogenic cyst or tumor over 1.25 cm in diameter

Removal of nonodontogenic cyst or tumor up to 1.25 cm in diameter

Removal of nonodontogenic cyst or tumor over 1.25 cm in diameter

Destruction of lesions by physical methods: electrosurgery, chemotherapy, cryotherapy

N/C

N/C

N/C

N/C

N/C

EXCISION OF BONE TISSUE

 

Removal of overgrowth of bone - upper or lower

Partial ostectomy (guttering or saucerization)

Radical removal of mandible with bone graft

N/C

N/C

N/C

SURGICAL INCISION

 

Incision and drainage of abscess - intraoral

Incision and drainage of abscess - extraoral

Removal of foreign body, skin, or subcutaneous aveolar tissue

Removal of reaction-producing foreign bodies - musculoskeletal system

Removal of dead bone

Maxillary sinusotomy for removal of tooth fragment or foreign body

N/C

N/C

N/C

N/C

N/C

N/C

OTHER REPAIRS

 

Frenulectomy - separate procedure (frenectomy or frenotomy)

Excision of hyperplastic tissue (per arch)

Removal of stone in salivary gland

Replacement of salivary duct

General Anesthetic

N/C

N/C

N/C

N/C

N/C

ENDODONTICS

 

Molar root canal filling

Removal of portion of root (separate procedure) - first root

Removal of portion of root (separate procedure) - each additional root

Removal of portion of root in conjunction with endo - per root

Retrograde filling

Separation of roots of tooth

Root amputation

$200

$100

$85

$115

$40

$80

$80

   
   N/C = No Charge    

 
 
  © Copyright 2001-2008 Delta Dental of New Jersey, Inc. All Rights Reserved. Legal | Privacy