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 an interim denture
D5120 Complete denture - mandibular – Limit 1 every 60 months – Denied if using as an interim denture
D5130 Immediate denture – maxillary – Limit 1 every 60 months – Denied if using as an interim denture
D5140 Immediate denture - mandibular – Limit 1 every 60 months – Denied if using as an interim denture
D5211 Maxillary partial denture - resin base (including retentive/clasping materials, rests, and teeth) – Limit 1 every 60 months - Denied if using as an interim denture
D5212 Mandibular partial denture - resin base (including retentive/clasping materials, rests, and teeth) – Limit 1 every 60 months - Denied if using as an interim 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 an interim denture
D5222 Immediate mandibular partial denture – resin base (including retentive/clasping materials, rests and teeth) - Limit 1 every 60 months – Denied if using as an interim 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 an interim denture
D5226 Mandibular partial denture – flexible base (including retentive/clasping materials, rests, and teeth) – Limit 1 every 60 months - Denied if using as an interim denture
D5227 Immediate maxillary partial denture – flexible base (including any clasps, rests, and teeth) – Limit 1 every 60 months – Denied if using as an interim denture
D5228 Immediate mandibular partial denture – flexible base (including any clasps, rests, and teeth) – Limit 1 every 60 months – Denied if using as an interim 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
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 predominantly 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 predominantly 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 Resin retainer - resin bonded fixed prosthesis - Limit 1 every 60 months
D6600 Retainer inlay - porcelain/ceramic, two surfaces - Limit 1 every 60 months - An alternate benefit will be provided
D6601 Retainer inlay - porcelain/ceramic, three or more surfaces - Limit 1 every 60 months - An alternate benefit will be provided
D6602 Retainer inlay - cast high noble metal, two surfaces – Limit 1 every 60 months
D6603 Retainer inlay - cast high noble metal, three or more surfaces – Limit 1 every 60 months
D6604 Retainer inlay - cast predominantly base metal, two surfaces - Limit 1 every 60 months
D6605 Retainer inlay - cast predominantly base metal, three or more surfaces - Limit 1 every 60 months
D6606 Retainer inlay - cast noble metal, two surfaces – Limit 1 every 60 months
D6607 Retainer inlay - cast noble metal, three or more surfaces – Limit 1 every 60 months
D6608 Retainer onlay - porcelain/ceramic, two surfaces - Limit 1 every 60 months - An alternate benefit will be provided
D6609 Retainer onlay - porcelain/ceramic, three or more surfaces - Limit 1 every 60 months - An alternate benefit will be provided
D6610 Retainer onlay - cast high noble metal, two surfaces – Limit 1 every 60 months
D6611 Retainer onlay - cast high noble metal, three or more surfaces – Limit 1 every 60 months
D6612 Retainer onlay - cast predominantly base metal, two surfaces – Limit 1 every 60 months
D6613 Retainer onlay - cast predominantly base metal, three or more surfaces – Limit 1 every 60 months
D6614 Retainer onlay - cast noble metal, two surfaces – Limit 1 every 60 months
D6615 Retainer onlay - cast noble metal, three or more surfaces – Limit 1 every 60 months
D6624 Retainer inlay – titanium – Limit 1 every 60 months
D6634 Retainer onlay - titanium – Limit 1 every 60 months
D6710 Retainer crown - indirect resin based composite - Limit 1 every 60 months
D6720 Retainer crown - resin with high noble metal - Limit 1 every 60 months
D6721 Retainer crown - resin with predominantly base metal - Limit 1 every 60 months
D6722 Retainer crown - resin with noble metal – Limit 1 every 60 months
D6740 Retainer crown - porcelain/ceramic – Limit 1 every 60 months
D6750 Retainer crown - porcelain fused to high noble metal - Limit 1 every 60 months
D6751 Retainer crown - porcelain fused to predominantly base metal – Limit 1 every 60 months
D6752 Retainer crown - porcelain fused to noble metal - Limit 1 every 60 months
D6753 Retainer crown – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months
D6780 Retainer crown - 3/4 cast high noble metal - Limit 1 every 60 months
D6781 Retainer crown - 3/4 cast predominately base metal - Limit 1 every 60 months
D6782 Retainer crown - 3/4 cast noble metal – Limit 1 every 60 months
D6783 Retainer crown - 3/4 porcelain/ceramic – Limit 1 every 60 months
D6784 Retainer crown ¾ – titanium and titanium alloys - Limit 1 every 60 months
D6790 Retainer crown - full cast high noble metal - Limit 1 every 60 months
D6791 Retainer crown - full cast predominantly base metal - Limit 1 every 60 months
D6792 Retainer crown - full cast noble metal - Limit 1 every 60 months
D6794 Retainer crown - titanium and titanium alloys - Limit 1 every 60 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
D5120 Complete denture - mandibular – Limit 1 every 60 months – Denied if using as an interim denture
D5130 Immediate denture – maxillary – Limit 1 every 60 months – Denied if using as an interim denture
D5140 Immediate denture - mandibular – Limit 1 every 60 months – Denied if using as an interim denture
D5211 Maxillary partial denture - resin base (including retentive/clasping materials, rests, and teeth) – Limit 1 every 60 months - Denied if using as an interim denture
D5212 Mandibular partial denture - resin base (including retentive/clasping materials, rests, and teeth) – Limit 1 every 60 months - Denied if using as an interim 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 an interim denture
D5222 Immediate mandibular partial denture – resin base (including retentive/clasping materials, rests and teeth) - Limit 1 every 60 months – Denied if using as an interim 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 an interim denture
D5226 Mandibular partial denture – flexible base (including retentive/clasping materials, rests, and teeth) – Limit 1 every 60 months - Denied if using as an interim denture
D5227 Immediate maxillary partial denture – flexible base (including any clasps, rests, and teeth) – Limit 1 every 60 months – Denied if using as an interim denture
D5228 Immediate mandibular partial denture – flexible base (including any clasps, rests, and teeth) – Limit 1 every 60 months – Denied if using as an interim 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
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 predominantly 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 predominantly 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 Resin retainer - resin bonded fixed prosthesis - Limit 1 every 60 months
D6600 Retainer inlay - porcelain/ceramic, two surfaces - Limit 1 every 60 months - An alternate benefit will be provided
D6601 Retainer inlay - porcelain/ceramic, three or more surfaces - Limit 1 every 60 months - An alternate benefit will be provided
D6602 Retainer inlay - cast high noble metal, two surfaces – Limit 1 every 60 months
D6603 Retainer inlay - cast high noble metal, three or more surfaces – Limit 1 every 60 months
D6604 Retainer inlay - cast predominantly base metal, two surfaces - Limit 1 every 60 months
D6605 Retainer inlay - cast predominantly base metal, three or more surfaces - Limit 1 every 60 months
D6606 Retainer inlay - cast noble metal, two surfaces – Limit 1 every 60 months
D6607 Retainer inlay - cast noble metal, three or more surfaces – Limit 1 every 60 months
D6608 Retainer onlay - porcelain/ceramic, two surfaces - Limit 1 every 60 months - An alternate benefit will be provided
D6609 Retainer onlay - porcelain/ceramic, three or more surfaces - Limit 1 every 60 months - An alternate benefit will be provided
D6610 Retainer onlay - cast high noble metal, two surfaces – Limit 1 every 60 months
D6611 Retainer onlay - cast high noble metal, three or more surfaces – Limit 1 every 60 months
D6612 Retainer onlay - cast predominantly base metal, two surfaces – Limit 1 every 60 months
D6613 Retainer onlay - cast predominantly base metal, three or more surfaces – Limit 1 every 60 months
D6614 Retainer onlay - cast noble metal, two surfaces – Limit 1 every 60 months
D6615 Retainer onlay - cast noble metal, three or more surfaces – Limit 1 every 60 months
D6624 Retainer inlay – titanium – Limit 1 every 60 months
D6634 Retainer onlay - titanium – Limit 1 every 60 months
D6710 Retainer crown - indirect resin based composite - Limit 1 every 60 months
D6720 Retainer crown - resin with high noble metal - Limit 1 every 60 months
D6721 Retainer crown - resin with predominantly base metal - Limit 1 every 60 months
D6722 Retainer crown - resin with noble metal – Limit 1 every 60 months
D6740 Retainer crown - porcelain/ceramic – Limit 1 every 60 months
D6750 Retainer crown - porcelain fused to high noble metal - Limit 1 every 60 months
D6751 Retainer crown - porcelain fused to predominantly base metal – Limit 1 every 60 months
D6752 Retainer crown - porcelain fused to noble metal - Limit 1 every 60 months
D6753 Retainer crown – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months
D6780 Retainer crown - 3/4 cast high noble metal - Limit 1 every 60 months
D6781 Retainer crown - 3/4 cast predominately base metal - Limit 1 every 60 months
D6782 Retainer crown - 3/4 cast noble metal – Limit 1 every 60 months
D6783 Retainer crown - 3/4 porcelain/ceramic – Limit 1 every 60 months
D6784 Retainer crown ¾ – titanium and titanium alloys - Limit 1 every 60 months
D6790 Retainer crown - full cast high noble metal - Limit 1 every 60 months
D6791 Retainer crown - full cast predominantly base metal - Limit 1 every 60 months
D6792 Retainer crown - full cast noble metal - Limit 1 every 60 months
D6794 Retainer crown - titanium and titanium alloys - Limit 1 every 60 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 Prosthodontic Services Notes:
- For reporting and benefit purposes, the completion date for fixed partial dentures is the cementation date. The completion date is the insertion date for removable prosthodontic appliances. For immediate dentures, the dentist who fabricated the denture may be reimbursed for the service after insertion by another dentist (e.g., oral surgeon).
- All major restorative and prosthodontic services (i.e., crown, bridges, implants and dentures) are combined under one replacement limitation under the plan. Benefits for major restorative and prosthodontic services are combined and limited to one every 60 months per tooth or arch depending on the service. For example, if benefits for a removable 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.)