Improve your smile and overall well-being with Dental Health Services Great oral health is essential for your overall well-being. With a Dental Health Services plan, you can achieve a healthy smile while enjoying excellent benefits, such as: Low out-of-pocket costs - You pay low, predictable copayments so you know exactly how much you ll owe before you even schedule your appointment. Enjoy affordable, hassle-free coverage with no surprises! Experience the Dental Health Services Difference today! Locally-based Employee-owned Great coverage - A broad range of general dental procedures are covered, from exams, to x-rays, cleanings, sealants, amalgam & composite restorations, crowns, bridges, dentures and extractions. Bilingual Member Service Specialists with extensive dental experience Prompt treatment - You ll be able to get the help you need, with no waiting periods, no annual benefit maximums, and easy appointment scheduling. Access to great dentists who adhere to our 17-point Quality Assurancesm program Enroll in a Dental Health Services plan and get covered today! 3833 Atlantic Avenue, Long Beach, CA 987 562-595-6 www.dentalhealthservices.com 813OM14 213 Dental Health Services H5928_14_9_MK Accepted
Schedule of Covered Services and Copayments Care1st Health Plan - Kern Choice Plan (HMO) Code Description Copayment Code Description Copayment Diagnostic D12 D14 D15 D16 D17 D18 D21 D22 D23 D24 D D26 D27 D272 D273 D274 D277 D33 Failed/no-show general dentist appointment without 24-hour notice Office Visit Periodic oral evaluation - established patient Limited oral evaluation - problem focused Comprehensive oral evaluation - new or established patient Detailed and extensive oral evaluation - problem focused, by report Re-evaluation - limited, problem focused (established patient; not post-operative visit) Comprehensive periodontal evaluation - new or established patient Intraoral - complete series of radiographic images Intraoral - periapical first radiographic image Intraoral - periapical each additional radiographic image Intraoral - occlusal radiographic image Extraoral - first radiographic image Extraoral - each additional radiographic image Bitewing - single radiographic image Bitewings - two radiographic images Bitewings - three radiographic images Bitewings - four radiographic images Vertical bitewings - 7 to 8 radiographic images Panoramic radiographic image 2 D391 D46 D47 Preventive D111 D128 D131 D132 D133 Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report Pulp vitality tests Diagnostic casts Prophylaxis - adult (limited to 1 per 6 months & additional at higher copayments) Topical application of fluoride Nutritional counseling for control of dental disease Tobacco counseling for the control and prevention of oral disease Oral hygiene instructions Space Maintainers D151 D1515 D152 D15 D155 D1555 Space maintainer - fixed - unilateral Space maintainer - fixed - bilateral Space maintainer - removable - unilateral Space maintainer - removable - bilateral Re-cementation of space maintainer Removal of fixed space maintainer Amalgam Restorations - Primary or Permanent D214 Amalgam - one surface, primary or permanent D215 Amalgam - two, primary or permanent D216 Amalgam - three, primary or permanent D2161 Amalgam - four or more, primary or permanent Resin-Based Composite Restorations D233 D2331 Resin-based composite - one surface, anterior Resin-based composite - two, anterior 5 5 5 7 4 5 3 35 4 3 4 913M566 Current Dental Terminology 213 American Dental Association. All rights reserved
D2332 Resin-based composite - three 45 D2663 Onlay - resin-based composite -, anterior three D2335 Resin-based composite - four or 5 D2664 Onlay - resin-based composite - more or involving incisal angle (anterior) D271 four or more Crown - resin-based composite 15 D239 Resin-based composite crown, 12 (indirect) anterior D2712 Crown - ¾ resin-based composite 15 D2391 Resin-based composite - one surface, posterior 11 D272 * (indirect) Crown - resin with high noble 15 D2392 Resin-based composite - two 13 D2721 Crown - resin with predominantly, posterior 15 D2393 Resin-based composite - three 15 D2722 * Crown - resin with noble 15, posterior D274 * Crown - porcelain/ceramic 28 D2394 Resin-based composite - four or 18 substrate more, posterior D275 * Crown - porcelain fused to high 28 Crowns - Single Restoration Only noble D2751 Crown - porcelain fused to 28 *Additional charges of $1 for noble, $15 for high noble predominantly. Add $1 for porcelain on molars, $5 for porcelain butt margin, $2 for specialized crowns such as Lava, Captek, D2752 * Crown - porcelain fused to noble 28 Empress, Procera, etc. D278 D1 * Inlay - lic - one surface 23 * Crown - 3/4 cast high noble 23 D2781 Crown - 3/4 cast predominantly 23 D2 * Inlay - lic - two 23 D3 * Inlay - lic - three or more 23 D2782 * Crown - 3/4 cast noble 23 D2783 D42 * Onlay - lic - two 23 * Crown - 3/4 porcelain/ceramic 28 D279 D43 * Onlay - lic - three 23 * Crown - full cast high noble 23 D2791 Crown - full cast predominantly 23 D44 * Onlay - lic - four or more 23 D2792 D261 * Inlay - porcelain/ceramic - one 31 * Crown - full cast noble 23 surface D2794 * Crown - titanium 23 D262 * Inlay - porcelain/ceramic - two 33 Other Restorative Services D291 Recement inlay, onlay, or partial 2 D263 * Inlay - porcelain/ceramic - three or 33 coverage restoration more D2915 Recement cast or prefabricated 2 D2642 * Onlay - porcelain/ceramic - two 33 post and core D292 Recement crown 2 D2643 * Onlay - porcelain/ceramic - three 33 D293 Prefabricated stainless steel crown - 6 primary tooth D2644 * Onlay - porcelain/ceramic - four or 33 more D2931 Prefabricated stainless steel crown - 6 permanent tooth D265 Inlay - resin-based composite - one 23 surface D2932 Prefabricated resin crown 6 D2651 Inlay - resin-based composite - two D2933 Prefabricated stainless steel crown 8 with resin window D2652 Inlay - resin-based composite - D2934 Prefabricated esthetic coated 8 three or more stainless steel crown - primary tooth D2662 Onlay - resin-based composite - D294 Protective restoration two D295 Core buildup, including any pins 3 when required 913M566 Current Dental Terminology 213 American Dental Association. All rights reserved
D2951 Pin retention - per tooth, in 2 D3332 Incomplete endodontic therapy; 8 addition to restoration inoperable, unrestorable or D2952 Post and core in addition to crown, 7 fractured tooth indirectly fabricated D3333 Internal root repair of perforation 5 D2953 Each additional indirectly defects fabricated post - same tooth D3346 Retreatment of previous root canal 2 D2954 Prefabricated post and core in 55 therapy - anterior addition to crown D3347 Retreatment of previous root canal 32 D2955 Post removal 55 therapy - bicuspid D2957 Each additional prefabricated D3351 Apexification/recalcification 35 post - same tooth initial visit (apical closure/calcific D296 Labial veneer (resin laminate) - 24 repair of perforations, root chairside resorption, pulp space disinfection, etc.) D2961 Labial veneer (resin laminate) - 28 laboratory D3352 Apexification/recalcification - 35 interim medication replacement D2962 Labial veneer (porcelain laminate) - 36 (apical closure/calcific repair of laboratory perforations, root resorption, pulp D2971 Additional procedures to construct space disinfection, etc.) new crown under existing partial D3353 Apexification/recalcification - final 35 denture framework visit (includes completed root canal D2975 Coping 23 therapy - apical closure/calcific Endodontics repair of perforations, root resorption, etc.) D311 Pulp cap - direct (excluding final 12 D395 Canal preparation and fitting of restoration) preformed dowel or post D312 Pulp cap - indirect (excluding final 6 restoration) Periodontics 55 D322 Therapeutic pulpotomy (excluding 17 D4211 Gingivectomy or gingivoplasty - 6 final restoration) - removal of pulp one to three contiguous teeth or coronal to the dentinocemental tooth bounded spaces per quadrant junction and application of D424 Gingival flap procedure, including medicament root planing - four or more D3221 Pulpal debridement, primary and 17 contiguous teeth or tooth bounded permanent teeth spaces per quadrant D323 D324 D331 D332 D333 D3331 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) Endodontic therapy, anterior tooth (excluding final restoration) Endodontic therapy, bicuspid tooth (excluding final restoration) Endodontic therapy, molar (excluding final restoration) Treatment of root canal obstruction; non-surgical access 6 7 15 22 3 5 D4241 D4277 D4341 D4342 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous tooth position in graft Periodontal scaling and root planing - four or more teeth per quadrant Periodontal scaling and root planing - one to three teeth per quadrant 2 32 5 913M566 Current Dental Terminology 213 American Dental Association. All rights reserved
D4355 Full mouth debridement to enable 5 D551 Repair broken complete denture 3 D4381 comprehensive evaluation and diagnosis Localized delivery of antimicrobial 5 D552 base Replace missing or broken teeth - complete denture (each tooth) 2 agents via controlled release vehicle D561 Repair resin denture base 3 into diseased crevicular tissue, per D562 Repair cast framework 5 tooth D563 Repair or replace broken clasp 4 D491 Periodontal maintenance (limited 5 D564 Replace broken teeth - per tooth 2 to 1 per 6 months & additional at higher copayments) D565 Add tooth to existing partial 2 denture D4999 Unspecified periodontal procedure, by report D566 Add clasp to existing partial denture 3 D567 Replace all teeth and acrylic on cast 22 Dentures framework (maxillary) Dentures and partials include four months free adjustments. Add lab cost of any gold. D5671 Replace all teeth and acrylic on cast framework (mandibular) 22 D511 Complete denture - maxillary 35 D571 Rebase complete maxillary denture 14 D512 Complete denture - mandibular 35 D5711 Rebase complete mandibular 14 D513 Immediate denture - maxillary 36 denture D514 Immediate denture - mandibular 36 D572 Rebase maxillary partial denture 14 D5211 Maxillary partial denture - resin 2 D5721 Rebase mandibular partial denture 14 base (including any conventional D573 Reline complete maxillary denture 8 clasps, rests and teeth) (chairside) D5212 Mandibular partial denture - resin 2 D5731 Reline complete mandibular 8 base (including any conventional denture (chairside) clasps, rests and teeth) D574 Reline maxillary partial denture 8 D5213 Maxillary partial denture - cast 38 (chairside) framework with resin D5741 Reline mandibular partial denture 8 denture bases (including any conventional clasps, rests and teeth) D575 (chairside) Reline complete maxillary denture 14 D5214 Mandibular partial denture - cast 38 (laboratory) framework with resin D5751 Reline complete mandibular 14 denture bases (including any conventional clasps, rests and teeth) D576 denture (laboratory) Reline maxillary partial denture 14 D52 Maxillary partial denture - flexible 58 (laboratory) base (including any clasps, rests D5761 Reline mandibular partial denture and teeth) (laboratory) 14 D5226 Mandibular partial denture - 58 D581 Interim complete denture 14 flexible base (including any clasps, (maxillary) rests and teeth) D5811 Interim complete denture 14 D5281 Removable unilateral partial 15 (mandibular) denture - one piece cast D582 Interim partial denture (maxillary) 14 (including clasps and teeth) D5821 Interim partial denture (mandibular) 14 Denture Adjustments & Repairs D585 Tissue conditioning, maxillary 4 D541 Adjust complete denture - maxillary D5851 Tissue conditioning, mandibular 4 D5411 Adjust complete denture - mandibular D5421 Adjust partial denture - maxillary D5422 Adjust partial denture - mandibular 913M566 Current Dental Terminology 213 American Dental Association. All rights reserved
Bridges D6611 * Onlay - cast high noble, three 23 *Additional charges of $1 for noble, $15 for high noble. Add $1 for porcelain on molars, $5 for porcelain butt D6612 or more Onlay - cast predominantly base 23 margin, $2 for specialized crowns such as Lava, Captek, Empress, Procera, etc. D6613, two Onlay - cast predominantly base 23 D6 Pontic - indirect resin based 13, three or more composite D6614 * Onlay - cast noble, two 23 D621 * Pontic - cast high noble 23 D6211 Pontic - cast predominantly base 23 D6615 * Onlay - cast noble, three or 23 more D6212 * Pontic - cast noble 23 D6624 * Inlay - titanium 23 D6214 * Pontic - titanium 23 D6634 * Onlay - titanium 23 D624 * Pontic - porcelain fused to high 28 D671 Crown - indirect resin based 13 noble composite D6241 Pontic - porcelain fused to 28 D672 * Crown - resin with high noble 13 predominantly D6721 Crown - resin with predominantly 13 D6242 * Pontic - porcelain fused to noble 28 D6722 * Crown - resin with noble 13 D6245 * Pontic - porcelain/ceramic 28 D674 * Crown - porcelain/ceramic 28 D6 * Pontic - resin with high noble 13 D675 * Crown - porcelain fused to high 28 D61 Pontic - resin with predominantly 13 noble D6751 Crown - porcelain fused to 28 D62 * Pontic - resin with noble 13 predominantly D6545 Retainer - cast for resin 18 D6752 * Crown - porcelain fused to noble 28 bonded fixed prosthesis D6548 Retainer - porcelain/ceramic for 18 D678 * Crown - 3/4 cast high noble 23 resin bonded fixed prosthesis D6781 Crown - 3/4 cast predominantly 23 D66 * Inlay - porcelain/ceramic, two 28 D6782 * Crown - 3/4 cast noble 28 D661 * Inlay - porcelain/ceramic, three or 28 D6783 * Crown - 3/4 porcelain/ceramic 28 more D679 * Crown - full cast high noble 23 D662 * Inlay - cast high noble, two 23 D6791 Crown - full cast predominantly 23 D663 * Inlay - cast high noble, three 23 D6792 * Crown - full cast noble 23 or more D6794 * Crown - titanium 23 D664 Inlay - cast predominantly base 23 D693 Recement fixed partial denture 2, two D6975 Coping 7 D665 Inlay - cast predominantly base 23, three or more Oral Surgery D666 * Inlay - cast noble, two 23 D7111 Extraction, coronal remnants - 3 deciduous tooth D667 * Inlay - cast noble, three or 23 D714 Extraction, erupted tooth or 35 D668 * more Onlay - porcelain/ceramic, two 28 D721 exposed root (elevation and/or forceps removal) Surgical removal of erupted tooth 1 D669 * Onlay - porcelain/ceramic, three or 28 requiring removal of bone and/or more sectioning of tooth, and including D661 * Onlay - cast high noble, two 23 elevation of mucoperiosteal flap if indicated 913M566 Current Dental Terminology 213 American Dental Association. All rights reserved
D727 D731 D7311 D732 D7321 D751 D7511 Other Services D911 D9215 D931 D944 D945 D963 D994 D9941 D9942 D9972 D9973 D9974 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant Incision and drainage of abscess - intraoral soft tissue Incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces) Palliative (emergency) treatment of dental pain - minor procedure Local anesthesia in conjunction with operative or surgical procedures Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician Office visit - after regularly scheduled hours Case presentation, detailed and extensive treatment planning Other drugs and/or medicaments, by report Occlusal guard, by report Fabrication of athletic mouthguard Repair and/or reline of occlusal guard External bleaching - per arch - performed in office External bleaching - per tooth Internal bleaching - per tooth 8 8 8 8 1 1 1 2 5 18 1 9 2 1 1 Orthodontics Please call your Dental Health Services Member Service Specialist at 8-637-6453 for a referral to a conveniently located affiliated orthodontist. Orthodontic models, x-rays, photographs and records are not covered. There may be additional copayments depending on treatment needs. Consultation Failed/no-show appointment without 24-hour notice Full banded - child, up to age 19 1775 Full banded - adult 1975 Partial banded - child, up to age 19 1 Partial banded - adult 145 Mixed dentition - phase 1 45 Palatal expansion 35 Rapid palatal expansion 55 Retention appliance - after 18 orthodontic treatment Functional appliance (Bionator- 55 Frankel) Headgear 35 Simple crossbite 275 Copying records 4 Care1st is a Medicare Advantage HMO plan with a Federal Government contract and State Medicaid contract in Arizona and California. Enrollment in Care1st Health Plan depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Benefits and/or co-payments/coinsurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply. Care1st Health Plan Member Services: 1-8-544-88 (TTY/TDD users call 711), 8am 8pm, 7 days a week. 913M566 Current Dental Terminology 213 American Dental Association. All rights reserved