Blue Cross Blue Shield FEP Dental
Class B Intermediate

D2140 Amalgam – one surface, primary or permanent - Limit 1 every 24 months per surface per tooth

D2150 Amalgam – two surfaces, primary or permanent - Limit 1 every 24 month per surface per tooth

D2160 Amalgam – three surfaces, primary or permanent - Limit 1 every 24 months per surface per tooth

D2161 Amalgam – four or more surfaces, primary or permanent - Limit 1 every 24 months per surface per tooth

D2330 Resin-based composite – one surface, anterior - Limit 1 every 24 months per surface per tooth

D2331 Resin-based composite – two surfaces, anterior - Limit 1 every 24 months per surface per tooth

D2332 Resin-based composite – three surfaces, anterior - Limit 1 every 24 months per surface per tooth

D2335 Resin-based composite – four or more surfaces (anterior) - Limit 1 every 24 months per surface per tooth

D2390 Resin-based composite crown, anterior - Limit every 24 months per tooth

D2391 Resin-based composite – one surface, posterior - Limit 1 every 24 months per surface per tooth

D2392 Resin-based composite – two surfaces, posterior - Limit 1 every 24 months per surface per tooth

D2393 Resin-based composite – three surfaces, posterior - Limit 1 every 24 months per surface per tooth

D2394 Resin-based composite – four or more surfaces, posterior - Limit 1 every 24 months per surface per tooth

D2510 Inlay - metallic - one surface - Limit 1 per tooth every 60 months - An alternate benefit will be provided

D2520 Inlay - metallic - two surfaces - Limit 1 per tooth every 60 months - An alternate benefit will be provided

D2530 Inlay - metallic - three or more surfaces - Limit 1 per tooth every 60 months - An alternate benefit will be provided

D2610 Inlay - porcelain/ceramic - one surface - Limit 1 every 60 months - An alternate benefit will be provided

D2620 Inlay - porcelain/ceramic - two surfaces - Limit 1 every 60 months - An alternate benefit will be provided

D2630 Inlay - porcelain/ceramic - three or more surfaces - Limit 1 every 60 months - An alternate benefit will be provided

D2650 Inlay - resin-based composite - one surface - Limit 1 every 60 months - An alternate benefit will be provided

D2651 Inlay - resin-based composite - two surfaces - Limit 1 every 60 months - An alternate benefit will be provided

D2652 Inlay - resin-based composite - three or more surfaces - Limit 1 every 60 months - An alternate benefit will be provided

D2910 Re-cement or re-bond inlay, onlay veneer or partial coverage restoration - Limit 1 every 6 months after initial installation, if less than 6 months from installation, no patient liability

D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core - Limit 1 every 6 months after initial installation, if less than 6 months from installation, no patient liability

D2920 Re-cement or re-bond crown - Limit 1 every 6 months after initial installation, if less than 6 months from installation, no patient liability

D2921 Reattachment of tooth fragment, incisal edge or cusp - Limit to 1 every 24 months per surface per tooth, included with fillings

D2928 Prefabricated porcelain/ceramic crown – permanent tooth – Limit 1 every tooth every 60 months for patients up to age 15 – an alternate benefit will be provided

D2929 Prefabricated porcelain/ceramic crown – primary tooth – Limit 1 per tooth every 60 months for patients up to age 15 - an alternate benefit will be provided

D2930 Prefabricated stainless steel crown - primary tooth – Limit 1 per tooth every 60 months for patients up to age 15

D2931 Prefabricated stainless steel crown – permanent tooth – Limit 1 per tooth every 60 months for patients up to age 15

D2940 Placement of interim direct restoration

D2951 Pin retention – per tooth, in addition to restoration

D2989 Excavation of a tooth resulting in the determination of non-restorability - Limit 1 per tooth per lifetime

D7288 Brush biopsy - transepithelial sample collection - Limit 1 every 12 months

Class B Intermediate Minor Restorative Services Notes:

• Restorations are covered benefits only when necessary to replace tooth structure due to fracture or decay