Blue Cross Blue Shield FEP Dental
Section 5 Dental Services and Supplies Class A Basic
Section 5 Dental Services and Supplies Class A Basic
Preventive Services
D1110 Prophylaxis – Adult: Limit 3 during the calendar year. Age 13 and under will be processed as D1120 - additional information on the following page.
D1120 Prophylaxis – Child: Limit 3 during the calendar year. Age 14 and over will be processed as D1110 - additional information on the following page.
D1206 Topical application of fluoride - varnish - Limit 2 during the calendar year for patients up to age 22 in combination with D1208
D1208 Topical application of fluoride - excluding varnish - Limit 2 during the calendar year for patients up to age 22 in combination with D1206
D1351 Sealant - per tooth - unrestored permanent molars for patient up to age 22- any combination of a sealant or a preventive resin restoration - Limit 1 every 36 months
D1352 Preventive resin restorations in a moderate to high caries risk patient - unrestored - permanent tooth for patient up to age 22 - any combination of a sealant or a preventive resin restoration - Limit 1 every 36 months
D1353 Sealant repair - per unrestored permanent molar for patient up to age 22 - any combination of a sealant or preventive resin restoration - Limit 1 every 36 months
D1354 Application of caries arresting medicament per tooth
D1510 Space maintainer - fixed - unilateral - per quadrant - Limited to patients up to age 22
D1516 Space maintainer – fixed – bilateral, maxillary- Limited to patients up to age 22
D1517 Space maintainer – fixed – bilateral, mandibular - Limited to patients up to age 22
D1520 Space maintainer - removable - unilateral - per quadrant - Limited to patients up to age 22
D1526 space maintainer – removable – bilateral, maxillary - Limited to patients up to age 22
D1527 space maintainer – removable – bilateral, mandibular - Limited to patients up to age 22
D1551 Re-cement or re-bond bilateral space maintainer - maxillary
D1552 Re-cement or re-bond bilateral space maintainer – mandibular
D1553 Re-cement or re-bond unilateral space maintainer – per quadrant
D1556 Removal of fixed unilateral space maintainer – per quadrant. Allowed if removed by dentist or dental practice that did not originally place the appliance
D1557 Removal of fixed bilateral space maintainer – maxillary. Allowed if removed by dentist or dental practice that did not originally place the appliance.
D1558 Removal of fixed bilateral space maintainer – mandibular. Allowed if removed by dentist or dental practice that did not originally place the appliance
D1575 Distal shoe space maintainer - Fixed – Unilateral - per quadrant - Limited to patients up to age 22
D1120 Prophylaxis – Child: Limit 3 during the calendar year. Age 14 and over will be processed as D1110 - additional information on the following page.
D1206 Topical application of fluoride - varnish - Limit 2 during the calendar year for patients up to age 22 in combination with D1208
D1208 Topical application of fluoride - excluding varnish - Limit 2 during the calendar year for patients up to age 22 in combination with D1206
D1351 Sealant - per tooth - unrestored permanent molars for patient up to age 22- any combination of a sealant or a preventive resin restoration - Limit 1 every 36 months
D1352 Preventive resin restorations in a moderate to high caries risk patient - unrestored - permanent tooth for patient up to age 22 - any combination of a sealant or a preventive resin restoration - Limit 1 every 36 months
D1353 Sealant repair - per unrestored permanent molar for patient up to age 22 - any combination of a sealant or preventive resin restoration - Limit 1 every 36 months
D1354 Application of caries arresting medicament per tooth
D1510 Space maintainer - fixed - unilateral - per quadrant - Limited to patients up to age 22
D1516 Space maintainer – fixed – bilateral, maxillary- Limited to patients up to age 22
D1517 Space maintainer – fixed – bilateral, mandibular - Limited to patients up to age 22
D1520 Space maintainer - removable - unilateral - per quadrant - Limited to patients up to age 22
D1526 space maintainer – removable – bilateral, maxillary - Limited to patients up to age 22
D1527 space maintainer – removable – bilateral, mandibular - Limited to patients up to age 22
D1551 Re-cement or re-bond bilateral space maintainer - maxillary
D1552 Re-cement or re-bond bilateral space maintainer – mandibular
D1553 Re-cement or re-bond unilateral space maintainer – per quadrant
D1556 Removal of fixed unilateral space maintainer – per quadrant. Allowed if removed by dentist or dental practice that did not originally place the appliance
D1557 Removal of fixed bilateral space maintainer – maxillary. Allowed if removed by dentist or dental practice that did not originally place the appliance.
D1558 Removal of fixed bilateral space maintainer – mandibular. Allowed if removed by dentist or dental practice that did not originally place the appliance
D1575 Distal shoe space maintainer - Fixed – Unilateral - per quadrant - Limited to patients up to age 22