Blue Cross Blue Shield FEP Dental
Class C Major

D0160 Detailed and extensive oral evaluation - problem focused, by report - Limit 2 during the calendar year for any combination of oral evaluations

D2410 Gold Foil – one surface – Limit 1 every 24 months - An alternate benefit will be provided

D2420 Gold Foil – two surfaces – Limit 1 every 24 months - An alternate benefit will be provided

D2430 Gold Foil – three surfaces – Limit 1 every 24 months - An alternate benefit will be provided

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 surfaces - Limit 1 per tooth every 60 months - An alternate benefit will be provided

D2542 Onlay - metallic - two surfaces - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2543 Onlay - metallic - three surfaces - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2544 Onlay - metallic - four or more surfaces - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2642 Onlay-porcelain/ceramic - two surfaces - Limit 1 per tooth every 60 months

D2643 Onlay-porcelain/ceramic - three surfaces - Limit 1 per tooth every 60 months

D2644 Onlay porcelain/ceramic - four or more surfaces - Limit 1 per tooth every 60 months

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

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

D2652 Inlay - resin-based composite - three surfaces, lab proc - Limit 1 every 60 months - An alternate benefit will be provided

D2662 Onlay - resin-based composite - two surfaces, lab proc - Limit 1 every 60 months

D2663 Onlay - resin-based composite - three surfaces, lab proc - Limit 1 per tooth every 60 months

D2664 Onlay - resin-based composite - four or more surfaces, lab proc - Limit 1 per tooth every 60 months

D2710 Crown - resin-based composite, lab proc - Limit 1 every 60 months

D2712 Crown 3/4 resin, lab proc - Limit 1 per tooth every 60 months

D2720 Crown resin with high noble metal - Limit 1 per tooth every 60 months

D2721 Crown resin with predominantly base metal - Limit 1 per tooth every 60 months

D2722 Crown resin with noble metal - Limit 1 per tooth every 60 months

D2740 Crown - porcelain/ceramic - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2750 Crown - porcelain fused to high noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2751 Crown - porcelain fused to predominately base metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2752 Crown - porcelain fused to noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2753 Crown - porcelain fused to titanium and titanium alloys- Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2780 Crown - 3/4 cast high noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2781 Crown - 3/4 cast predominately base metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2782 Crown - 3/4 cast noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2783 Crown - 3/4 porcelain/ceramic - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics. Denied if done on an anterior tooth.

D2790 Crown - full cast high noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2791 Crown - full cast predominately base metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2792 Crown - full cast noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2794 Crown - titanium and titanium alloys - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2932 Crown prefabricated resin – Limit 1 per tooth every 60 months for patients up to age 15, including crowns, bridges, prosthetics

D2933 Crown prefabricated stainless steel crown/resin window - Limit 1 per tooth every 60 months for patients up to age of 15 - alternate benefit will be provided

D2934 Prefabricated esthetic coated stainless steel crown, primary tooth – Limit 1 per tooth every 60 months for patients, including crowns, bridges, prosthetics

D2950 Core buildup, including any pins - Limit 1 build up procedure, per tooth every 60 months

D2952 Cast post and core in addition to crown - Limit 1 build up procedure, every 60 months

D2954 Prefabricated post and core, in addition to crown - Limit 1 build up procedure, per tooth every 60 months

D2955 Post removal, not in conjunction with endodontic

D2971 Additional procedures to customize a crown to fit under existing partial denture framework - Limit 1 every 60 months

D2980 Crown repair, by report – Limit 1 every 12 months

D2981 Inlay Repair - Limit 1 every 12 months

D2982 Onlay Repair – Limit 1 every 12 months

D2983 Veneer Repair – Limit 1 every 12 months

D2990 Resin infiltration of incipient smooth surface lesions