Blue Cross Blue Shield FEP Dental
Class C Major
Class C Major
Prosthodontic Services
D5110 Complete denture – maxillary – Limit 1 every 60 months – Denied if using as a temporary denture.
D5120 Complete denture - mandibular – Limit 1 every 60 months – Denied if using as a temporary denture.
D5130 Immediate denture – maxillary – Limit 1 every 60 months – Denied if using as a temporary denture.
D5140 Immediate denture - mandibular – Limit 1 every 60 months – Denied if using as a temporary denture.
D5211 Maxillary partial denture - resin base (including retentive/clasping materials, rests, and teeth) – Limit 1 every 60 months. Denied if using as a temporary denture.
D5212 Mandibular partial denture - resin base (including retentive/clasping materials, rests, and teeth) – Limit 1 every 60 months. Denied if using as a temporary denture.
D5213 Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) – Limit 1 every 60 months
D5214 Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) – Limit 1 every 60 months
D5221 Immediate maxillary partial denture, resin base – (including retentive/clasping materials, rests and teeth) - Limit 1 every 60 months – Denied if using as a temporary denture.
D5222 Immediate mandibular partial denture, resin base – (including retentive/clasping materials, rests and teeth) - Limit 1 every 60 months – Denied if using as a temporary denture.
D5223 Immediate maxillary partial denture, cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) -Limit 1 every 60 months
D5224 Immediate mandibular partial denture, cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)- Limit 1 every 60 months
D5225 Maxillary partial denture – flexible base (including retentive/clasping materials, rests and teeth)– Limit 1 every 60 months - Denied if using as a temporary denture.
D5226 Mandibular partial denture – flexible base (including retentive/clasping materials, rests and teeth) – Limit 1 every 60 months - Denied if using as a temporary denture.
D5227 Immediate maxillary partial denture – flexible base (including any clasps, rest and teeth) – Limit 1 every 60 months – Denied if using as a temporary denture.
D5228 Immediate mandibular partial denture – flexible base (including any clasps, rest and teeth) – Limit 1 every 60 months – Denied if using as a temporary denture.
D5282 Removable unilateral partial denture - one piece cast metal (including retentive/clasping materials, rests and teeth), maxillary - Limit 1 every 60 months
D5283 Removable unilateral partial denture – one piece cast metal (including retentive/clasping materials, rests and teeth), mandibular - Limit 1 every 60 months
D5863 Overdenture – complete maxillary - Limit 1 every 60 months - an alternate benefit will be provided
D5864 Overdenture – partial maxillary - Limit 1 every 60 months - an alternate benefit will be provided
D5865 Overdenture – complete mandibular - Limit 1 every 60 months - an alternate benefit will be provided
D5866 Overdenture – partial mandibular - Limit 1 every 60 months - an alternate benefit will be provided
D5876 Add metal substructure to acrylic full denture (per arch) – Limit 1 every 60 months
D6010 Endosteal Implant – surgical placement – Limit 1 per tooth every 60 months
D6012 Surgical Placement of Interim Implant Body for transitional prosthesis: endosteal implant– Limit 1 per tooth every 60 months
D6013 Mini Implant – Limit 1 per tooth every 60 months
D6040 Eposteal Implant – Limit 1 per tooth every 60 months
D6050 Transosteal Implant, including hardware – Limit 1 per tooth every 60 months
D6055 Connecting Bar – implant or abutment supported – Limit 1 every 60 months
D6056 Prefabricated Abutment - includes modification and placement – Limit 1 every 60 months
D6057 Custom fabricated abutment - includes modification and placement – Limit 1 every 60 months
D6058 Abutment supported porcelain ceramic crown – Limit 1 every 60 months
D6059 Abutment supported porcelain fused to metal crown - high noble metal - Limit 1 every 60 months
D6060 Abutment supported porcelain fused to metal crown - predominately base metal - Limit 1 every 60 months
D6061 Abutment supported porcelain fused to metal crown - noble metal - Limit 1 every 60 months
D6062 Abutment supported cast metal crown - high noble metal - Limit 1 every 60 months
D6063 Abutment supported cast metal crown - predominately base metal – Limit 1 every 60 months
D6064 Abutment supported cast noble metal crown - noble metal – Limit 1 every 60 months
D6065 Implant supported porcelain/ceramic crown – Limit 1 every 60 months
D6066 Implant supported crown porcelain fused to high noble alloys – Limit 1 every 60 months
D6067 Implant supported crown - high noble alloys – Limit 1 every 60 months
D6068 Abutment supported retainer for porcelain/ceramic FPD – Limit 1 every 60 months
D6069 Abutment supported retainer for porcelain fused to metal FPD - high noble metal – Limit 1 every 60 months
D6070 Abutment supported retainer for porcelain fused to metal FPD - predominately base metal – Limit 1 every 60 months
D6071 Abutment supported retainer for porcelain fused to metal FPD - noble metal – Limit 1 every 60 months
D6072 Abutment supported retainer for cast metal FPD - high noble metal – Limit 1 every 60 months
D6073 Abutment supported retainer for cast metal FPD - predominately base metal - Limit 1 every 60 months
D6074 Abutment supported retainer for cast metal FPD - noble metal - Limit 1 every 60 months
D6075 Implant supported retainer for ceramic FPD – Limit 1 every 60 months
D6076 Implant supported retainer for FPD porcelain fused to high noble alloys - Limit 1 every 60 months
D6077 Implant supported retainer for metal FPD - high noble alloys – Limit 1 every 60 months
D6080 Implant Maintenance Procedures – Limit 1 every 60 months
D6082 Implant supported crown – porcelain fused to predominantly base alloys - Limit 1 every 60 months
D6083 Implant supported crown – porcelain fused to noble alloys - Limit 1 every 60 months
D6084 Implant supported crown – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months
D6086 Implant supported crown – predominantly base alloys - Limit 1 every 60 months
D6087 Implant supported crown – noble alloys - Limit 1 every 60 months
D6088 Implant supported crown – titanium and titanium alloys - Limit 1 every 60 months
D6090 Repair Implant Prosthesis – Limit 1 every 60 months
D6091 Replacement of replaceable part of Semi-Precision or Precision Attachment of implant/abutment supported prosthesis, per attachment – Limit 1 every 60 months
D6092 Recement Implant/abutment supported crown - Limit 1 every 60 months
D6093 Recement Implant/abutment supported fixed partial denture – Limit 1 every 60 months
D6094 Abutment supported crown - titanium and titanium alloys - Limit 1 every 60 months
D6095 Repair Implant Abutment – Limit 1 every 60 months
D6097 Abutment supported crown – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months
D6098 Implant supported retainer – porcelain fused to predominantly base alloys - Limit 1 every 60 months
D6099 Implant supported retainer for FPD – porcelain fused to noble alloys - Limit 1 every 60 months
D6100 Implant Removal, by report – Limit once per implant location
D6101 Debridement of a periimplant defect and surface cleaning of exposed implant surfaces, including flap entry and closure – Limit 1 per lifetime
D6102 Debridement and osseous contouring of a periimplant defect; include surface cleaning of exposed implant surfaces and flap entry and closure – Limit 1 per lifetime
D6103 Bone graft for repair of periimplant defect – not including flap entry and closure or, when indicated, placement of a barrier membrane or biologi materials to aid in osseous regeneration - Limit 1 every 36 months
D6104 Bone graft at time of implant placement - Limit 1 every 36 months
D6110 Implant supported removable denture for edentulous arch - Maxillary - Limit 1 every 60 months
D6111 Implant supported removable denture for edentulous arch - Mandibular - Limit 1 every 60 months
D6112 Implant supported removable denture for partially edentulous arch - Maxillary - Limit 1 every 60 months
D6113 Implant supported removable denture for partially edentulous arch - Mandibular - Limit 1 every 60 months
D6114 Implant supportedfixed denture for edentulous arch - Maxillary - Limit 1 every 60 months
D6115 Implant supported fixed denture for edentulous arch - Mandibular - Limit 1 every 60 months
D6116 Implant supported fixed denture for partially edentulous arch - Maxillary - Limit 1 every 60 months
D6117 Implant supported fixed denture for partially edentulous arch - Mandibular - Limit 1 every 60 months
D6120 Implant supported retainer – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months
D6121 Implant supported retainer for metal FPD – predominantly base alloys - Limit 1 every 60 months
D6122 Implant supported retainer for metal FPD – noble alloys - Limit 1 every 60 months
D6123 Implant supported retainer for metal FPD – titanium and titanium alloys - Limit 1 every 60 months
D6190 Implant Index – Limit 1 every 60 months
D6191 Semi-precision abutment – placement – Limit 1 every 60 months
D6192 Semi-precision attachment – placement – Limit 1 every 60 months
D6194 Abutment supported retainer crown for FPD - titanium and titanium alloys - Limit 1 every 60 months
D6195 Abutment supported retainer – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months
D6205 Pontic – indirect resin based composite – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6210 Pontic - cast high noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6211 Pontic - cast predominately base metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6212 Pontic - cast noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6214 Pontic - titanium and titanium alloys - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6240 Pontic - porcelain fused to high noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6241 Pontic - porcelain fused to predominately base metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6242 Pontic - porcelain fused to noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6243 Pontic – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6245 Pontic - porcelain/ceramic - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6250 Pontic – resin with high noble metal – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6251 Pontic - resin with predominantly base metal – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6252 Pontic - resin with noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6545 Retainer - cast metal for resin bonded fixed prosthesis - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis - Limit 1 every 60 months, including all other crowns, bridges, prosthetics - An alternate benefit will be provided
D6549 Retainer - Resin for resin bonded fixed prosthesis - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6600 Inlay - porcelain/ceramic - 2 surfaces - Limit 1 every 60 months, including all other crowns, bridges, prosthetics - An alternate benefit will be provided
D6601 Inlay/onlay - porcelain/ceramic, three or more surfaces - Limit 1 every 60 months, including all other crowns, bridges, prosthetics - An alternate benefit will be provided
D6602 Inlay-cast high noble metal, 2 surfaces – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6603 Inlay-cast high noble metal, 3 + surfaces – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6604 Inlay - cast predominantly base metal, two surfaces - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6605 Inlay - cast predominantly base metal, three or more surfaces - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6606 Inlay - cast noble metal, 2 surfaces – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6607 Inlay - cast noble metal, 3 + surfaces – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6608 Retainer Onlay - Porcelain/Ceramic, 2 or more surfaces - Limit 1 every 60 months, including all other crowns, bridges, prosthetics - An alternate benefit will be provided
D6609 Retainer Onlay - Porcelain/Ceramic, 3 or more surfaces, including all other crowns, bridges, prosthetics - Limit 1 every 60 months - An alternate benefit will be provided
D6610 Onlay - cast high noble metal, 2 surfaces – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6611 Onlay - cast high noble metal, 3 + surfaces – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6612 Onlay - cast predominantly base metal, 2 + surfaces – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6613 Onlay - cast predominantly base metal, 3 + surfaces – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6614 Onlay - cast noble metal, 2 surfaces – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6615 Onlay - cast noble metal, 3 + surfaces – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6624 Inlay – cast titanium metal – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6634 Onlay - cast titanium metal – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6710 Crown - indirect resin based composite - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6720 Crown - Resin with high noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6721 Crown - resin with predominantly base metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6722 Crown - resin with noble metal – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6740 Crown - porcelain/ceramic – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6750 Crown - porcelain fused to high noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6751 Crown - porcelain fused to predominately base metal – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6752 Crown - porcelain fused to noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6753 Retainer crown – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6780 Crown - 3/4 cast high noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6781 Crown - 3/4 cast predominately base metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6782 Crown - 3/4 cast noble metal – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6783 Crown - 3/4 porcelain/ceramic – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6784 Retainer crown ¾ – titanium and titanium alloys - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6790 Crown - full cast high noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6791 Crown - full cast predominately base metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6792 Crown - full cast noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6794 Crown - Retainer crown titanium and titanium alloys - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D7340 Vestibuloplasty - Ridge extension (secondary epithelialization)
D7350 Vestibuloplasty - Ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue)
D7994 Surgical placement zygomatic implant – Limit 1 per tooth every 6 months
D9932 Cleaning and inspection of removable complete denture maxillary – Limit 3 times per calendar year
D9933 Cleaning and inspection of removable complete denture mandibular – Limit 3 times per calendar year
D9934 Cleaning and inspection of removable partial denture maxillary – Limit 3 times per calendar year
D9935 Cleaning and inspection of removable partial denture mandibular – Limit 3 times per calendar year
Class C Major Notes:
D5120 Complete denture - mandibular – Limit 1 every 60 months – Denied if using as a temporary denture.
D5130 Immediate denture – maxillary – Limit 1 every 60 months – Denied if using as a temporary denture.
D5140 Immediate denture - mandibular – Limit 1 every 60 months – Denied if using as a temporary denture.
D5211 Maxillary partial denture - resin base (including retentive/clasping materials, rests, and teeth) – Limit 1 every 60 months. Denied if using as a temporary denture.
D5212 Mandibular partial denture - resin base (including retentive/clasping materials, rests, and teeth) – Limit 1 every 60 months. Denied if using as a temporary denture.
D5213 Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) – Limit 1 every 60 months
D5214 Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) – Limit 1 every 60 months
D5221 Immediate maxillary partial denture, resin base – (including retentive/clasping materials, rests and teeth) - Limit 1 every 60 months – Denied if using as a temporary denture.
D5222 Immediate mandibular partial denture, resin base – (including retentive/clasping materials, rests and teeth) - Limit 1 every 60 months – Denied if using as a temporary denture.
D5223 Immediate maxillary partial denture, cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) -Limit 1 every 60 months
D5224 Immediate mandibular partial denture, cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)- Limit 1 every 60 months
D5225 Maxillary partial denture – flexible base (including retentive/clasping materials, rests and teeth)– Limit 1 every 60 months - Denied if using as a temporary denture.
D5226 Mandibular partial denture – flexible base (including retentive/clasping materials, rests and teeth) – Limit 1 every 60 months - Denied if using as a temporary denture.
D5227 Immediate maxillary partial denture – flexible base (including any clasps, rest and teeth) – Limit 1 every 60 months – Denied if using as a temporary denture.
D5228 Immediate mandibular partial denture – flexible base (including any clasps, rest and teeth) – Limit 1 every 60 months – Denied if using as a temporary denture.
D5282 Removable unilateral partial denture - one piece cast metal (including retentive/clasping materials, rests and teeth), maxillary - Limit 1 every 60 months
D5283 Removable unilateral partial denture – one piece cast metal (including retentive/clasping materials, rests and teeth), mandibular - Limit 1 every 60 months
D5863 Overdenture – complete maxillary - Limit 1 every 60 months - an alternate benefit will be provided
D5864 Overdenture – partial maxillary - Limit 1 every 60 months - an alternate benefit will be provided
D5865 Overdenture – complete mandibular - Limit 1 every 60 months - an alternate benefit will be provided
D5866 Overdenture – partial mandibular - Limit 1 every 60 months - an alternate benefit will be provided
D5876 Add metal substructure to acrylic full denture (per arch) – Limit 1 every 60 months
D6010 Endosteal Implant – surgical placement – Limit 1 per tooth every 60 months
D6012 Surgical Placement of Interim Implant Body for transitional prosthesis: endosteal implant– Limit 1 per tooth every 60 months
D6013 Mini Implant – Limit 1 per tooth every 60 months
D6040 Eposteal Implant – Limit 1 per tooth every 60 months
D6050 Transosteal Implant, including hardware – Limit 1 per tooth every 60 months
D6055 Connecting Bar – implant or abutment supported – Limit 1 every 60 months
D6056 Prefabricated Abutment - includes modification and placement – Limit 1 every 60 months
D6057 Custom fabricated abutment - includes modification and placement – Limit 1 every 60 months
D6058 Abutment supported porcelain ceramic crown – Limit 1 every 60 months
D6059 Abutment supported porcelain fused to metal crown - high noble metal - Limit 1 every 60 months
D6060 Abutment supported porcelain fused to metal crown - predominately base metal - Limit 1 every 60 months
D6061 Abutment supported porcelain fused to metal crown - noble metal - Limit 1 every 60 months
D6062 Abutment supported cast metal crown - high noble metal - Limit 1 every 60 months
D6063 Abutment supported cast metal crown - predominately base metal – Limit 1 every 60 months
D6064 Abutment supported cast noble metal crown - noble metal – Limit 1 every 60 months
D6065 Implant supported porcelain/ceramic crown – Limit 1 every 60 months
D6066 Implant supported crown porcelain fused to high noble alloys – Limit 1 every 60 months
D6067 Implant supported crown - high noble alloys – Limit 1 every 60 months
D6068 Abutment supported retainer for porcelain/ceramic FPD – Limit 1 every 60 months
D6069 Abutment supported retainer for porcelain fused to metal FPD - high noble metal – Limit 1 every 60 months
D6070 Abutment supported retainer for porcelain fused to metal FPD - predominately base metal – Limit 1 every 60 months
D6071 Abutment supported retainer for porcelain fused to metal FPD - noble metal – Limit 1 every 60 months
D6072 Abutment supported retainer for cast metal FPD - high noble metal – Limit 1 every 60 months
D6073 Abutment supported retainer for cast metal FPD - predominately base metal - Limit 1 every 60 months
D6074 Abutment supported retainer for cast metal FPD - noble metal - Limit 1 every 60 months
D6075 Implant supported retainer for ceramic FPD – Limit 1 every 60 months
D6076 Implant supported retainer for FPD porcelain fused to high noble alloys - Limit 1 every 60 months
D6077 Implant supported retainer for metal FPD - high noble alloys – Limit 1 every 60 months
D6080 Implant Maintenance Procedures – Limit 1 every 60 months
D6082 Implant supported crown – porcelain fused to predominantly base alloys - Limit 1 every 60 months
D6083 Implant supported crown – porcelain fused to noble alloys - Limit 1 every 60 months
D6084 Implant supported crown – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months
D6086 Implant supported crown – predominantly base alloys - Limit 1 every 60 months
D6087 Implant supported crown – noble alloys - Limit 1 every 60 months
D6088 Implant supported crown – titanium and titanium alloys - Limit 1 every 60 months
D6090 Repair Implant Prosthesis – Limit 1 every 60 months
D6091 Replacement of replaceable part of Semi-Precision or Precision Attachment of implant/abutment supported prosthesis, per attachment – Limit 1 every 60 months
D6092 Recement Implant/abutment supported crown - Limit 1 every 60 months
D6093 Recement Implant/abutment supported fixed partial denture – Limit 1 every 60 months
D6094 Abutment supported crown - titanium and titanium alloys - Limit 1 every 60 months
D6095 Repair Implant Abutment – Limit 1 every 60 months
D6097 Abutment supported crown – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months
D6098 Implant supported retainer – porcelain fused to predominantly base alloys - Limit 1 every 60 months
D6099 Implant supported retainer for FPD – porcelain fused to noble alloys - Limit 1 every 60 months
D6100 Implant Removal, by report – Limit once per implant location
D6101 Debridement of a periimplant defect and surface cleaning of exposed implant surfaces, including flap entry and closure – Limit 1 per lifetime
D6102 Debridement and osseous contouring of a periimplant defect; include surface cleaning of exposed implant surfaces and flap entry and closure – Limit 1 per lifetime
D6103 Bone graft for repair of periimplant defect – not including flap entry and closure or, when indicated, placement of a barrier membrane or biologi materials to aid in osseous regeneration - Limit 1 every 36 months
D6104 Bone graft at time of implant placement - Limit 1 every 36 months
D6110 Implant supported removable denture for edentulous arch - Maxillary - Limit 1 every 60 months
D6111 Implant supported removable denture for edentulous arch - Mandibular - Limit 1 every 60 months
D6112 Implant supported removable denture for partially edentulous arch - Maxillary - Limit 1 every 60 months
D6113 Implant supported removable denture for partially edentulous arch - Mandibular - Limit 1 every 60 months
D6114 Implant supportedfixed denture for edentulous arch - Maxillary - Limit 1 every 60 months
D6115 Implant supported fixed denture for edentulous arch - Mandibular - Limit 1 every 60 months
D6116 Implant supported fixed denture for partially edentulous arch - Maxillary - Limit 1 every 60 months
D6117 Implant supported fixed denture for partially edentulous arch - Mandibular - Limit 1 every 60 months
D6120 Implant supported retainer – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months
D6121 Implant supported retainer for metal FPD – predominantly base alloys - Limit 1 every 60 months
D6122 Implant supported retainer for metal FPD – noble alloys - Limit 1 every 60 months
D6123 Implant supported retainer for metal FPD – titanium and titanium alloys - Limit 1 every 60 months
D6190 Implant Index – Limit 1 every 60 months
D6191 Semi-precision abutment – placement – Limit 1 every 60 months
D6192 Semi-precision attachment – placement – Limit 1 every 60 months
D6194 Abutment supported retainer crown for FPD - titanium and titanium alloys - Limit 1 every 60 months
D6195 Abutment supported retainer – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months
D6205 Pontic – indirect resin based composite – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6210 Pontic - cast high noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6211 Pontic - cast predominately base metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6212 Pontic - cast noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6214 Pontic - titanium and titanium alloys - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6240 Pontic - porcelain fused to high noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6241 Pontic - porcelain fused to predominately base metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6242 Pontic - porcelain fused to noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6243 Pontic – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6245 Pontic - porcelain/ceramic - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6250 Pontic – resin with high noble metal – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6251 Pontic - resin with predominantly base metal – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6252 Pontic - resin with noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6545 Retainer - cast metal for resin bonded fixed prosthesis - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis - Limit 1 every 60 months, including all other crowns, bridges, prosthetics - An alternate benefit will be provided
D6549 Retainer - Resin for resin bonded fixed prosthesis - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6600 Inlay - porcelain/ceramic - 2 surfaces - Limit 1 every 60 months, including all other crowns, bridges, prosthetics - An alternate benefit will be provided
D6601 Inlay/onlay - porcelain/ceramic, three or more surfaces - Limit 1 every 60 months, including all other crowns, bridges, prosthetics - An alternate benefit will be provided
D6602 Inlay-cast high noble metal, 2 surfaces – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6603 Inlay-cast high noble metal, 3 + surfaces – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6604 Inlay - cast predominantly base metal, two surfaces - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6605 Inlay - cast predominantly base metal, three or more surfaces - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6606 Inlay - cast noble metal, 2 surfaces – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6607 Inlay - cast noble metal, 3 + surfaces – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6608 Retainer Onlay - Porcelain/Ceramic, 2 or more surfaces - Limit 1 every 60 months, including all other crowns, bridges, prosthetics - An alternate benefit will be provided
D6609 Retainer Onlay - Porcelain/Ceramic, 3 or more surfaces, including all other crowns, bridges, prosthetics - Limit 1 every 60 months - An alternate benefit will be provided
D6610 Onlay - cast high noble metal, 2 surfaces – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6611 Onlay - cast high noble metal, 3 + surfaces – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6612 Onlay - cast predominantly base metal, 2 + surfaces – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6613 Onlay - cast predominantly base metal, 3 + surfaces – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6614 Onlay - cast noble metal, 2 surfaces – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6615 Onlay - cast noble metal, 3 + surfaces – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6624 Inlay – cast titanium metal – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6634 Onlay - cast titanium metal – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6710 Crown - indirect resin based composite - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6720 Crown - Resin with high noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6721 Crown - resin with predominantly base metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6722 Crown - resin with noble metal – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6740 Crown - porcelain/ceramic – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6750 Crown - porcelain fused to high noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6751 Crown - porcelain fused to predominately base metal – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6752 Crown - porcelain fused to noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6753 Retainer crown – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6780 Crown - 3/4 cast high noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6781 Crown - 3/4 cast predominately base metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6782 Crown - 3/4 cast noble metal – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6783 Crown - 3/4 porcelain/ceramic – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6784 Retainer crown ¾ – titanium and titanium alloys - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6790 Crown - full cast high noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6791 Crown - full cast predominately base metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6792 Crown - full cast noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6794 Crown - Retainer crown titanium and titanium alloys - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D7340 Vestibuloplasty - Ridge extension (secondary epithelialization)
D7350 Vestibuloplasty - Ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue)
D7994 Surgical placement zygomatic implant – Limit 1 per tooth every 6 months
D9932 Cleaning and inspection of removable complete denture maxillary – Limit 3 times per calendar year
D9933 Cleaning and inspection of removable complete denture mandibular – Limit 3 times per calendar year
D9934 Cleaning and inspection of removable partial denture maxillary – Limit 3 times per calendar year
D9935 Cleaning and inspection of removable partial denture mandibular – Limit 3 times per calendar year
Class C Major Notes:
- All major prosthodontic services are combined under one replacement limitation under the plan. Benefits for prosthodontic services are combined and limited to one every 60 months. For example, if benefits for a partial denture are paid, this includes benefits to replace all missing teeth in the arch. No additional benefits for the arch would be considered until the 60 month replacement limit was met.
- When dental services that are subject to a frequency limitation were performed prior to your effective date of coverage the date of the prior service may be counted toward the time, frequency limitations and/or replacement limitations under this dental insurance. (For example, even if a crown, partial bridge, etc. was not placed while covered under BCBS FEP Dental, or paid by BCBS FEP Dental, the frequency limitations may apply.)