Blue Cross Blue Shield FEP Dental
Class B Intermediate
Class B Intermediate
Prosthodontic Services
D5410 Adjust complete denture – maxillary - Limit 1 per year beginning 6 months after the initial installation
D5411 Adjust complete denture – mandibular - Limit 1 per year beginning 6 months after the initial installation
D5421 Adjust partial denture – maxillary - Limit 1 per year beginning 6 months after the initial installation
D5422 Adjust partial denture – mandibular - Limit 1 per year beginning 6 months after the initial installation
D5511 Repair broken complete denture base mandibular - Limit 1 per year beginning 6 months after the initial installation
D5512 Repair broken complete denture base, maxillary - Limit 1 per year beginning 6 months after the initial installation
D5520 Replace missing or broken teeth – complete denture (each tooth) - Limit 1 per year beginning 6 months after the initial installation
D5611 Repair resin denture base mandibular - Limit 1 per year beginning 6 months after the initial installation
D5612 Repair resin partial denture base, maxillary - Limit 1 per year beginning 6 months after the initial installation
D5621 Repair cast framework, mandibular - Limit 1 per year beginning 6 months after the initial installation
D5622 Repair cast partial framework, maxillary - Limit 1 per year beginning 6 months after the initial installation
D5630 Repair or replace broken retentive/clasping materials per tooth - Limit 1 per year beginning 6 months after the initial installation
D5640 Replace broken teeth – per tooth - Limit 1 per year beginning 6 months after the initial installation
D5650 Add tooth to existing partial denture - Limit 1 per year beginning 6 months after the initial installation
D5660 Add clasp to existing partial denture - Limit 1 per year beginning 6 months after the initial installation
D5670 Replace all teeth and acrylic on cast metal framework, maxillary – Limit 2 every 24 months beginning 6 months after the initial installation
D5671 Replace all teeth and acrylic on cast metal framework, mandibular – Limit 2 every 24 months beginning 6 months after the initial installation
D5710 Rebase complete maxillary denture – Limit 1 every 36 months beginning 6 months after the initial installation
D5711 Rebase complete mandibular denture – Limit 1 every 36 months beginning 6 months after the initial installation
D5720 Rebase maxillary partial denture – Limit 1 every 36 months beginning 6 months after the initial installation
D5721 Rebase mandibular partial denture - Limit 1 every 36 months beginning 6 months after the initial installation
D5725 Rebase hybrid prosthesis – Limit 1 every 36 months beginning 6 months after the initial installation
D5730 Reline complete maxillary denture (direct) – Limit 1 every 36 months beginning 6 months after the initial installation
D5731 Reline complete mandibular denture (direct) - – Limit 1 every 36 months beginning 6 months after the initial installation
D5740 Reline maxillary partial denture (direct) – Limit 1 every 36 months beginning 6 months after the initial installation
D5741 Reline mandibular partial denture (direct) – Limit 1 every 36 months beginning 6 months after the initial installation
D5750 Reline complete maxillary denture (indirect) – Limit 1 every 36 months beginning 6 months after the initial installation
D5751 Reline complete mandibular denture (indirect) – Limit 1 every 36 months beginning 6 months after the initial installation
D5760 Reline maxillary partial denture (indirect) – Limit 1 every 36 months beginning 6 months after the initial installation
D5761 Reline mandibular partial denture (indirect) – Limit 1 every 36 months beginning 6 months after the initial installation
D5765 Soft liner for complete or partial removable denture – indirect – Limit 1 every 36 months beginning 6 months after the initial installation.
D5850 Tissue conditioning (maxillary)
D5851 Tissue conditioning (mandibular)
D6096 Remove broken implant retaining screw – Limit 1 every 60 months
D6930 Re-cement or re-bond fixed partial denture - Limit 1 per bridge beginning 6 months after the initial installation
D6980 Fixed partial denture repair, by report
D9120 Fixed partial denture sectioning - 1 per 60 Months
D5411 Adjust complete denture – mandibular - Limit 1 per year beginning 6 months after the initial installation
D5421 Adjust partial denture – maxillary - Limit 1 per year beginning 6 months after the initial installation
D5422 Adjust partial denture – mandibular - Limit 1 per year beginning 6 months after the initial installation
D5511 Repair broken complete denture base mandibular - Limit 1 per year beginning 6 months after the initial installation
D5512 Repair broken complete denture base, maxillary - Limit 1 per year beginning 6 months after the initial installation
D5520 Replace missing or broken teeth – complete denture (each tooth) - Limit 1 per year beginning 6 months after the initial installation
D5611 Repair resin denture base mandibular - Limit 1 per year beginning 6 months after the initial installation
D5612 Repair resin partial denture base, maxillary - Limit 1 per year beginning 6 months after the initial installation
D5621 Repair cast framework, mandibular - Limit 1 per year beginning 6 months after the initial installation
D5622 Repair cast partial framework, maxillary - Limit 1 per year beginning 6 months after the initial installation
D5630 Repair or replace broken retentive/clasping materials per tooth - Limit 1 per year beginning 6 months after the initial installation
D5640 Replace broken teeth – per tooth - Limit 1 per year beginning 6 months after the initial installation
D5650 Add tooth to existing partial denture - Limit 1 per year beginning 6 months after the initial installation
D5660 Add clasp to existing partial denture - Limit 1 per year beginning 6 months after the initial installation
D5670 Replace all teeth and acrylic on cast metal framework, maxillary – Limit 2 every 24 months beginning 6 months after the initial installation
D5671 Replace all teeth and acrylic on cast metal framework, mandibular – Limit 2 every 24 months beginning 6 months after the initial installation
D5710 Rebase complete maxillary denture – Limit 1 every 36 months beginning 6 months after the initial installation
D5711 Rebase complete mandibular denture – Limit 1 every 36 months beginning 6 months after the initial installation
D5720 Rebase maxillary partial denture – Limit 1 every 36 months beginning 6 months after the initial installation
D5721 Rebase mandibular partial denture - Limit 1 every 36 months beginning 6 months after the initial installation
D5725 Rebase hybrid prosthesis – Limit 1 every 36 months beginning 6 months after the initial installation
D5730 Reline complete maxillary denture (direct) – Limit 1 every 36 months beginning 6 months after the initial installation
D5731 Reline complete mandibular denture (direct) - – Limit 1 every 36 months beginning 6 months after the initial installation
D5740 Reline maxillary partial denture (direct) – Limit 1 every 36 months beginning 6 months after the initial installation
D5741 Reline mandibular partial denture (direct) – Limit 1 every 36 months beginning 6 months after the initial installation
D5750 Reline complete maxillary denture (indirect) – Limit 1 every 36 months beginning 6 months after the initial installation
D5751 Reline complete mandibular denture (indirect) – Limit 1 every 36 months beginning 6 months after the initial installation
D5760 Reline maxillary partial denture (indirect) – Limit 1 every 36 months beginning 6 months after the initial installation
D5761 Reline mandibular partial denture (indirect) – Limit 1 every 36 months beginning 6 months after the initial installation
D5765 Soft liner for complete or partial removable denture – indirect – Limit 1 every 36 months beginning 6 months after the initial installation.
D5850 Tissue conditioning (maxillary)
D5851 Tissue conditioning (mandibular)
D6096 Remove broken implant retaining screw – Limit 1 every 60 months
D6930 Re-cement or re-bond fixed partial denture - Limit 1 per bridge beginning 6 months after the initial installation
D6980 Fixed partial denture repair, by report
D9120 Fixed partial denture sectioning - 1 per 60 Months