CODE SERVICE FREQUENCY BENEFIT DETAILS Preventive Exams D0120 Routine check-up exam 2 procedures per Not covered within 6 months of calendar year receiving D0150 or D0180 D0140 Dental evaluation to 2 procedures per Not covered with any other exam evaluate a specific calendar year code on same day problem or complaint D0150 Comprehensive new 1 procedure every 3 Not covered within 3 years of patient exam calendar years receiving D0180 D0180 Exam for a new or 1 procedure every 3 Not covered within 3 years of established patient with calendar years receiving D0150 gum disease or risk factors such as smoking or diabetes D0191 Assessment of a Patient 2 procedures per Only covered on same day as calendar year receiving D9995 or D9996. Not covered when another exam code is submitted on same day. X-rays D0210 Full mouth set of X-rays 1 procedure every 3 Not covered within 3 years of calendar years receiving D0330 D0220 X-ray of entire tooth (first 1 procedure per Not covered on same day as image) date of service D0210 or D0330 D0230 X-ray of entire tooth Unlimited Not covered on same day as (additional images) D0210 or D0330 D0270 X-ray (bitewing 1 bitewing Not covered in same year as D0272 procedures) for diagnosing procedure code per D0210 D0273 cavities between teeth in calendar year the back of the mouth D0274 D0277 D0330 Panoramic X-ray of all the 1 procedure every 3 Not covered within 3 years of teeth and surrounding years receiving D0210 bone 2