Blue Cross Blue Shield FEP Dental
Class C Major
Class C Major
Implant Services
*D6010 Surgical placement of implant body: endosteal implant – Limit 1 per site every 60 months
*D6012 Surgical placement of interim implant body for transitional prosthesis: endosteal implant – Limit 1 per site every 60 months
*D6013 Surgical placement of mini implant – Limit 1 per site every 60 months
*D6040 Surgical placement: eposteal implant – Limit 1 per site every 60 months
*D6050 Surgical placement: transosteal implant – Limit 1 per site every 60 months
*D6055 Connecting bar – implant supported 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 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 (predominantly 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 (predominantly base metal) – Limit 1 every 60 months
*D6064 Abutment supported cast 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 (predominantly 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 (predominantly 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 when a full arch fixed hybrid prosthesis is removed and reinserted, including cleansing of prosthesis and abutments – 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
*D6089 Accessing and retorquing loose implant screw - per screw - Limit 1 per 12 months
*D6090 Repair of implant/abutment supported 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 Re-cement or re-bond implant/abutment supported crown - Limit 1 every 60 months
*D6093 Re-cement or re-bond implant/abutment supported fixed partial denture – Limit 1 every 60 months
*D6094 Abutment supported crown - titanium and titanium alloys - 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 Surgical removal of implant body – Limit once per implant location
*D6101 Debridement of a peri-implant defect or defects surrounding a single implant, and surface cleaning of the exposed implant surfaces, including flap entry and closure – Limit 1 per lifetime
*D6102 Debridement and osseous contouring of a peri-implant defect or defects surrounding a single implant and includes surface cleaning of the exposed implant surfaces, including flap entry and closure – Limit 1 per lifetime
*D6103 Bone graft for repair of peri-implant defect – does not include flap entry and closure - Limit 1 every 36 months
*D6104 Bone graft at time of implant placement - Limit 1 every 36 months
*D6105 Removal of implant body not requiring bone removal or flap elevation - Limit once per implant location
*D6106 Guided tissue regeneration – resorbable barrier, per implant - Limit 1 every 36 months
*D6107 Guided tissue regeneration – non-resorbable barrier, per implant - Limit 1 every 36 months
*D6110 Implant/abutment supported removable denture for edentulous arch - maxillary - Limit 1 every 60 months
*D6111 Implant/abutment supported removable denture for edentulous arch - mandibular - Limit 1 every 60 months
*D6112 Implant/abutment supported removable denture for partially edentulous arch - maxillary - Limit 1 every 60 months
*D6113 Implant/abutment supported removable denture for partially edentulous arch - mandibular - Limit 1 every 60 months
*D6114 Implant/abutment supported fixed denture for edentulous arch - maxillary - Limit 1 every 60 months
*D6115 Implant/abutment supported fixed denture for edentulous arch - mandibular - Limit 1 every 60 months
*D6116 Implant/abutment supported fixed denture for partially edentulous arch - maxillary - Limit 1 every 60 months
*D6117 Implant/abutment 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 Radiographic/surgical implant index, by report – 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
*D6012 Surgical placement of interim implant body for transitional prosthesis: endosteal implant – Limit 1 per site every 60 months
*D6013 Surgical placement of mini implant – Limit 1 per site every 60 months
*D6040 Surgical placement: eposteal implant – Limit 1 per site every 60 months
*D6050 Surgical placement: transosteal implant – Limit 1 per site every 60 months
*D6055 Connecting bar – implant supported 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 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 (predominantly 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 (predominantly base metal) – Limit 1 every 60 months
*D6064 Abutment supported cast 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 (predominantly 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 (predominantly 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 when a full arch fixed hybrid prosthesis is removed and reinserted, including cleansing of prosthesis and abutments – 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
*D6089 Accessing and retorquing loose implant screw - per screw - Limit 1 per 12 months
*D6090 Repair of implant/abutment supported 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 Re-cement or re-bond implant/abutment supported crown - Limit 1 every 60 months
*D6093 Re-cement or re-bond implant/abutment supported fixed partial denture – Limit 1 every 60 months
*D6094 Abutment supported crown - titanium and titanium alloys - 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 Surgical removal of implant body – Limit once per implant location
*D6101 Debridement of a peri-implant defect or defects surrounding a single implant, and surface cleaning of the exposed implant surfaces, including flap entry and closure – Limit 1 per lifetime
*D6102 Debridement and osseous contouring of a peri-implant defect or defects surrounding a single implant and includes surface cleaning of the exposed implant surfaces, including flap entry and closure – Limit 1 per lifetime
*D6103 Bone graft for repair of peri-implant defect – does not include flap entry and closure - Limit 1 every 36 months
*D6104 Bone graft at time of implant placement - Limit 1 every 36 months
*D6105 Removal of implant body not requiring bone removal or flap elevation - Limit once per implant location
*D6106 Guided tissue regeneration – resorbable barrier, per implant - Limit 1 every 36 months
*D6107 Guided tissue regeneration – non-resorbable barrier, per implant - Limit 1 every 36 months
*D6110 Implant/abutment supported removable denture for edentulous arch - maxillary - Limit 1 every 60 months
*D6111 Implant/abutment supported removable denture for edentulous arch - mandibular - Limit 1 every 60 months
*D6112 Implant/abutment supported removable denture for partially edentulous arch - maxillary - Limit 1 every 60 months
*D6113 Implant/abutment supported removable denture for partially edentulous arch - mandibular - Limit 1 every 60 months
*D6114 Implant/abutment supported fixed denture for edentulous arch - maxillary - Limit 1 every 60 months
*D6115 Implant/abutment supported fixed denture for edentulous arch - mandibular - Limit 1 every 60 months
*D6116 Implant/abutment supported fixed denture for partially edentulous arch - maxillary - Limit 1 every 60 months
*D6117 Implant/abutment 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 Radiographic/surgical implant index, by report – 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
Class C Major Implant Services Notes:
- Implant services listed with an asterisk (*) often have the choice of a lower cost treatment. If you or your provider should choose the more costly treatment or service, the lower cost alternate benefit will be allowed.
- 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.)