CODE SERVICE FREQUENCY BENEFIT DETAILS D0350 2D photographic image 1 procedure per Only covered when performed on calendar year same day as D9995 or D9996 D0801 3D dental surface scan, 1 of (D0801, D0802) direct every calendar year D0802 3D dental surface scan, 1 of (D0801, D0802) indirect every calendar year D0803 3D facial surface scan, 1 of (D0803, D0804) direct every calendar year D0804 3D facial surface scan, 1 of (D0803, D0804) indirect every calendar year Cleanings D1110 Routine adult dental 2 procedures per Cannot be performed on the cleaning calendar year same day as another type of cleaning (D4355, D4910, D4341, D4342) or gum surgery (D4210, D4211, D4240, D4241, D4260, D4261) Fluoride D1208 Topical fluoride treatment 2 procedures per 2 topical fluoride treatments calendar year (D1208) or desensitizing medication applications (D9910) per calendar year Comprehensive Fillings D2140 Silver-colored filling on Unlimited 1 procedure per surface per D2150 front, middle or back teeth tooth every 2 years D2160 D2161 D2330 White-colored filling on Unlimited 1 procedure per surface per D2331 front teeth tooth every 2 years D2332 D2335 3