Blue Cross Blue Shield FEP Dental Brochure - 2026
Blue Cross Blue Shield FEP Dental
Class C Major
Class C Major
Periodontal Services
D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant - Limit 1 every 36 months, 2 quadrants per date of service
D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months, 2 quadrants per date of service
D4212 Gingivectomy or gingivoplasty - to allow access for restorative procedure, per tooth – Limit 1 every 36 months, 2 quadrants per date of service
D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months, 2 quadrants per date of service
D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months, 2 quadrants per date of service
D4245 Apically positioned flap – Limit 1 every 36 months, permanent teeth only
D4249 Clinical crown lengthening – hard tissue
D4260 Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months, 2 quadrants per date of service
D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months, 2 quadrants per date of service
D4263 Bone replacement graft – retained natural tooth - first site in quadrant - Limit 1 every 36 months, permanent teeth only
D4264 Bone replacement graft – retained natural tooth - each additional site in quadrant - Limit 1 every 36 months, permanent teeth only
D4268 Surgical revision procedure, per tooth
D4270 Pedicle soft tissue graft procedure – Limit 1 every 36 months
D4273 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft – Limit 1 every 36 months
D4274 Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area) – Limit 1 every 36 months, permanent teeth only
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 (including recipient and donor surgical sites) first tooth, implant or edentulous tooth position in graft – Limit 1 every 36 months
D4278 Free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant or edentulous tooth position in same graft site – Limit 1 every 36 months
D4283 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) - each additional contiguous tooth, implant or edentulous tooth position in same graft site – Limit 1 every 36 months
D4285 Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material) - each additional contiguous tooth, implant or edentulous tooth position in same graft site – 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 Unspecified periodontal procedure, by report
D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months, 2 quadrants per date of service
D4212 Gingivectomy or gingivoplasty - to allow access for restorative procedure, per tooth – Limit 1 every 36 months, 2 quadrants per date of service
D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months, 2 quadrants per date of service
D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months, 2 quadrants per date of service
D4245 Apically positioned flap – Limit 1 every 36 months, permanent teeth only
D4249 Clinical crown lengthening – hard tissue
D4260 Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months, 2 quadrants per date of service
D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months, 2 quadrants per date of service
D4263 Bone replacement graft – retained natural tooth - first site in quadrant - Limit 1 every 36 months, permanent teeth only
D4264 Bone replacement graft – retained natural tooth - each additional site in quadrant - Limit 1 every 36 months, permanent teeth only
D4268 Surgical revision procedure, per tooth
D4270 Pedicle soft tissue graft procedure – Limit 1 every 36 months
D4273 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft – Limit 1 every 36 months
D4274 Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area) – Limit 1 every 36 months, permanent teeth only
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 (including recipient and donor surgical sites) first tooth, implant or edentulous tooth position in graft – Limit 1 every 36 months
D4278 Free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant or edentulous tooth position in same graft site – Limit 1 every 36 months
D4283 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) - each additional contiguous tooth, implant or edentulous tooth position in same graft site – Limit 1 every 36 months
D4285 Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material) - each additional contiguous tooth, implant or edentulous tooth position in same graft site – 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 Unspecified periodontal procedure, by report
Class C Periodontal Services Notes:
D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant and D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant are combined and limited to 1 every 36 months, 2 quadrants per date of service.
Gingivectomy or gingivoplasty performed in conjunction with restorative services are considered to be inclusive of the restoration and will not be reimbursed.
D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant and D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant are combined and limited to 1 every 36 months, 2 quadrants per date of service.
D4260 Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant and D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant are combined and limited to 1 every 36 months, 2 quadrants per date of service.
Clinical crown lengthening: Prior to final restoration of a tooth, a minimum of six weeks must be allowed for healing of bone and soft tissue following clinical crown lengthening.
D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant and D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant are combined and limited to 1 every 36 months, 2 quadrants per date of service.
Gingivectomy or gingivoplasty performed in conjunction with restorative services are considered to be inclusive of the restoration and will not be reimbursed.
D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant and D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant are combined and limited to 1 every 36 months, 2 quadrants per date of service.
D4260 Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant and D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant are combined and limited to 1 every 36 months, 2 quadrants per date of service.
Clinical crown lengthening: Prior to final restoration of a tooth, a minimum of six weeks must be allowed for healing of bone and soft tissue following clinical crown lengthening.