Blue Cross Blue Shield FEP Dental
Class C Major

D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces, per quadrant - Limit 1 every 36 months

D4211 Gingivectomy or gingivoplasty – one to three teeth, per quadrant – Limit 1 every 36 months

D4212 Gingivectomy or gingivoplasty - with restorative procedures, per tooth – Limit 1 every 36 months

D4240 Gingival flap procedure, including root planing, four or more contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months

D4241 Gingival flap procedure, including root planing, one to three contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months

D4245 Apically positioned flap – permanent teeth only - Limit 1 every 36 months

D4249 Clinical crown lengthening – hard tissue

D4260 Osseous surgery (including flap entry and closure), four or more contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months

D4261 Osseous surgery (including flap entry and closure), one to three contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months

D4263 Bone replacement graft – retained natural tooth - first site in quad – permanent teeth only - Limit 1 every 36 months

D4264 Bone replacement graft – retained natural tooth - each additional site in quad – permanent teeth only - Limit 1 every 36 months

D4268 Surgical revision procedure, per tooth

D4270 Pedicle soft tissue graft procedure – Limit 1 every 36 months

D4273 Autogenous connective tissue graft procedures first tooth (including donor and recipient surgical site) – Limit 1 every 36 months

D4274 Mesial/distal wedge procedure, single tooth – permanent teeth only - Limit 1 every 36 months

D4275 Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft - Limit 1 every 36 months

D4276 Combined connective tissue and pedicle graft, per tooth – Limit 1 every 36 months

D4277 Free soft tissue graft procedure, first tooth – Limit 1 every 36 months

D4278 Free soft tissue graft procedure - each additional contiguous tooth – Limit 1 every 36 months

D4283 Autogenous connective tissue graft procedure, each additional contiguous tooth (including donor and recipient surgical site) – Limit 1 every 36 months

D4285 Non-autogenous connective tissue graft procedure, each additional contiguous tooth (including recipient site and donor material) – Limit 1 every 36 months

D4355 Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis on a subsequent visit - Limit 1 per lifetime

D4999 Periodontal procedure, unspecified by report