Blue Cross Blue Shield FEP Dental
Section 5 Dental Services and Supplies Class A Basic

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 1st and 2nd 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 restoration in a moderate to high caries risk patient - unrestored 1st and 2nd 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 1st and 2nd 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

Class A Preventive Services Notes:

• Prophylaxis and scaling in presence of generalized moderate or severe gingival inflammation: Limit 3 per calendar year for any combination of D1110, D1120, and D4346, age 13 and under will be processed as D1120 and age 14 and over will be processed as D1110
• Treatments such as fluorides are combined under one limitation by the plan. For example, topical application of fluoride – varnish (D1206) and topical application of fluoride - excluding varnish (D1208) are combined and limited to 2 per calendar year for patients up to age 22