Procedure Description. Prophylaxis - adult. Periodic oral evaluation - established patient. Resin-based composite - three surfaces, posterior

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1 Top ADA Dental Procedure Codes - Pediatric Patients Ranked by Contribution to Total Pediatric Dental Claim Costs based on 15 Milliman Health Cost Guidelines-Dental Procedure Description Prophylaxis - adult Periodic oral evaluation - established patient Resin-based composite - two surfaces, posterior Topical application of fluoride - excluding varnish Sealant - per tooth Bitewings - four radiographic images Resin-based composite - one surface, posterior Prophylaxis - child removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated, erupted tooth or exposed root (elevation and/or forceps removal) Comprehensive oral evaluation - new or established patient Resin-based composite - three surfaces, posterior Removal of impacted tooth - completely bony Intraoral - complete series of radiographic images Limited oral evaluation - problem focused Panoramic radiographic image Amalgam - two surfaces, primary or permanent Topical application of fluoride varnish Intraoral - periapical first radiographic image Resin-based composite - one surface, anterior Procedure Type Fluoride Sealant Simple Fluoride

2 Resin-based composite - two surfaces, anterior Deep sedation/general anesthesia - first minutes Endodontic therapy, molar (excluding final restoration) Bitewings - two radiographic images Removal of impacted tooth - partially bony Resin-based composite - three surfaces, anterior Resin-based composite - four or more surfaces or involving incisal angle (anterior) Amalgam - one surface, primary or permanent Intraoral - periapical each additional radiographic image Anesthesia These codes are expected to represent approximately 97% of pediatric utilization and 91% of pediatric claim costs (excluding orthodontia). Others to Consider Including: 15 Space maintainer - fixed - unilateral 15 Space maintainer - fixed - bilateral Periodontal scaling and root planing - four or more teeth per quadrant Palliative (emergency) treatment of dental pain - minor procedure Space Maintainers Space Maintainers Emergency

3 Top ADA Dental Procedure Codes - Adult Patients Ranked by Contribution to Total Adult Dental Claim Costs based on 15 Milliman Health Cost Guidelines-Dental Procedure Description Prophylaxis - adult Periodic oral evaluation - established patient Crown - porcelain/ceramic substrate Resin-based composite - two surfaces, posterior Endodontic therapy, molar (excluding final restoration) Bitewings - four radiographic images Resin-based composite - one surface, posterior Periodontal scaling and root planing - four or more teeth per quadrant Periodontal maintenance Prophylaxis - child Crown - porcelain fused to noble metal Resin-based composite - three surfaces, posterior Comprehensive oral evaluation - new or established patient Crown - porcelain fused to predominantly base metal Intraoral - complete series of radiographic images Endodontic therapy, bicuspid tooth (excluding final restoration) removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated Panoramic radiographic image Procedure Type s s s s

4 Amalgam - two surfaces, primary or permanent Limited oral evaluation - problem focused Intraoral - periapical first radiographic image, erupted tooth or exposed root (elevation and/or forceps removal) Removal of impacted tooth - completely bony Resin-based composite - one surface, anterior Resin-based composite - two surfaces, anterior Bitewings - two radiographic images Crown - full cast high noble metal Resin-based composite - three surfaces, anterior Endodontic therapy, anterior tooth (excluding final restoration) Resin-based composite - four or more surfaces or involving incisal angle (anterior) Amalgam - one surface, primary or permanent Intraoral - periapical each additional radiographic image Amalgam - three surfaces, primary or permanent Pontic - porcelain fused to high noble metal Removal of impacted tooth - partially bony Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant Resin-based composite - four or more surfaces, posterior Periodontal scaling and root planing - one to three teeth per quadrant s Simple s s s Bridges s Bridges s These codes are expected to represent approximately 95% of adult utilization and 90% of adult claim costs (excluding orthodontia).

5 Others to Consider Including: Deep sedation/general anesthesia - first minutes 29 Prefabricated stainless steel crown - primary tooth Crown - full cast noble metal 52 Maxillary partial denture - cast metal framework with resin denture bases 13 (including any conventional clasps, rests and teeth) 51 Complete denture - maxillary 91 Palliative (emergency) treatment of dental pain - minor procedure 29 Re-cement or re-bond crown Anesthesia Dentures Dentures Emergency Repair (Simple)

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