CODE SERVICE FREQUENCY BENEFIT DETAILS Gum Surgery D4210 Surgical procedures that 1 procedure code Not covered if another cleaning D4211 treat periodontal disease per quadrant every (D1110, D4355, D4910) or deep D4240 (gum disease) to promote 3 calendar years, cleaning (D4341, D4342) is healing of gums and not to exceed 4 performed on the same day D4241 underlying bone unique quadrants D4260 every 3 calendar D4261 years Other Gum-Related Services D4341 Deep cleaning that’s 1 deep cleaning Not covered if another cleaning D4342 performed to remove procedure code per (D1110, D4355, D4910) or gum bacteria, plaque and tartar quadrant every 3 surgery procedure (D4210, below the gumline along calendar years, not D4211, D4240, D4241, D4260, the tooth roots to exceed 4 unique D4261) is performed on same quadrants every 3 day calendar years D4355 Cleaning that’s performed 1 procedure every 3 Not covered if another cleaning when there’s too much calendar years (D1110, D4910), deep cleaning tartar on the teeth to do an (D4341, D4342), or gum surgery effective exam procedure (D4210, D4211, D4240, D4241, D4260, D4261) is performed on same day D4381 Antimicrobial medicine 2 procedures per Only covered on same day that applied within the inflamed tooth per calendar D4910 is performed gum pocket around a tooth year, limited to 2 teeth per quadrant D4910 Routine dental cleaning for 3 procedures per Only covered with previous an adult with a history of calendar year history of receiving a deep gum disease cleaning (D4341, D4342) or gum surgery (D4210, D4211, D4240, D4241, D4260, D4261) Complete Dentures D5110 Complete upper denture 1 procedure every 5 Not covered within 5 years of (for patients missing all calendar years receiving an upper partial their upper teeth) denture (D5211, D5213, D5225) D5120 Complete lower denture 1 procedure every 5 Not covered within 5 years of (for patients missing all calendar years receiving a lower partial denture their bottom teeth) (D5212, D5214, D5226) 6