Teachers' Superannuation Commission Dentist Payment Schedule Teachers' Dental Plan Maximum Reimbursement Levels January 1, 2019 Teachers' Teachers' Dental Dental Description Code Plan Description Code Plan Level I 100% - Preventive Services - Reimbursed - once per 24 months 02601 71.00 at 100% of the dental charges to the maximums 02701 50.00 indicated below. 02702 71.00 02801 65.00 Oral Examination 02911 20.00 - new patient-primary 01101 54.00 02912 23.00 - new patient-mixed 01102 80.00 02913 25.00 - new patient - permanent 01103 109.00 Tests 04201 I.c. - new patient - limited 01201 45.00 04311 105.00 - previous patient 04312 112.00 (twice per year) 01202 35.50 04313 105.00 - specific 01204 44.00 04321 179.00 - emergency 01205 54.00 04322 197.00 Stomatognathic, dysfunctional 01301 114.00 04323 160.00 Prosthodontic 01701 74.00 04401 I.c. Orthodontic 04402 55.00 - new patient 01901 413.00 04501 86.00 - casts 04931 90.00 04509 86.00 Polishing 04721 56.00 (once per year) 11101 36.00 04722 112.00 Scaling * 11111 41.00 04723 168.00 (8 units per year) * 11112 82.00 Photographs 04811 32.00 * 11113 123.00 04812 48.00 * 11114 164.00 04813 64.00 * 11115 205.00 04819 16.00 * 11116 246.00 Study Models - unmounted * 04911 32.00 * 11117 20.50 - mounted * 04921 93.00 * 04922 173.00 (*2 units per year maximum reimbursed at 100% of Treatment Planning 05101 86.00 the dental charges indicated above.) 05102 172.00 (*6 units per year maximum reimbursed at 85% of 05201 86.00 the dental charges indicated above.) 05202 172.00 Topical Flouride Application 12111 17.00 Oral Hygiene Instruction 13211 33.00 (once per year) 12112 21.00 13217 16.00 X-Rays 12113 25.00 Sealants 13401 27.00 - full mouth 13409 18.00 (once per 24 months) 02102 149.00 13411 53.00 - bitewing/apicals 13419 41.00 (twice per year) 02111 23.00 Topical Application 13601 71.00 02112 31.00 13602 142.00 02113 40.00 Appliances 14101 229.00 02114 48.00 14102 229.00 02115 57.00 14103 459.00 02116 65.00 14201 251.00 02117 73.00 14202 251.00 02118 82.00 Mouth Guards 14501 52.00 02119 90.00 14502 84.00 02120 99.00 Space Maintainers 15101 121.00 02121 107.00 15103 228.00 02122 115.00 15105 228.00 02123 124.00 15201 160.00 02124 132.00 15202 170.00 02125 141.00 15301 160.00 02131 23.00 15302 220.00 02132 31.00 15401 186.00 02141 23.00 15402 188.00 02142 31.00 15403 160.00 02143 40.00 15501 160.00 02144 48.00 15601 48.00 02501 51.00 15603 48.00 02502 74.00 15604 48.00 02503 97.00 Anatomic Modifications 16101 72.00 02504 120.00 16201 86.00 16202 172.00 - Porcelain/Ceramic 25141 413.10 Level II 85% - Basic and Routine Services - 25142 535.50
Reimbusement at 85% of Dental charges to the 25143 577.15 maximums indicated below. 25144 577.15 Amalgam, Composite or 21111 84.15 Onlays - Metal 25511 646.00 Acrylic Fillings 21112 112.20 - Porcelain/Ceramic 25531 646.00 21113 128.35 Retentive Pins 21401 27.20 21114 145.35 21402 42.50 21115 162.35 21403 56.95 21121 93.50 21404 72.25 21122 125.80 21405 87.55 21123 143.65 25601 34.00 21124 163.20 25602 52.70 21125 181.90 25603 71.40 21211 107.95 25604 90.10 21212 146.20 25605 109.65 21213 167.45 Posts 25711 354.45 21214 189.55 25712 425.00 21215 211.65 25713 489.60 21221 122.40 25721 170.00 21222 164.90 25722 204.00 21223 188.70 25723 234.60 21224 213.35 Extractions 71101 124.95 21225 238.00 71109 93.50 21231 116.45 71201 208.25 21232 158.95 71209 155.55 21233 185.30 72111 206.55 21234 216.75 72211 283.05 21235 243.10 72221 385.90 21241 126.65 72231 425.00 21242 172.55 Dental Surgery (including x-rays and lab) 21243 201.45 - Residual Root 72311 96.90 21244 236.30 Removal 72319 73.10 21245 270.30 72321 202.30 21301 158.10 72329 152.15 21501 34.00 72331 269.45 22401 164.05 72339 202.30 22411 164.05 72511 206.55 22501 164.05 72521 271.15 22511 164.05 72531 333.20 23111 111.35 72711 307.70 23112 152.15 - Alveoplasty 73121 186.15 23113 179.35 73153 297.50 23114 209.10 73154 498.10 23115 251.60 73222 186.15 23311 129.20 73223 406.30 23312 176.80 73224 68.00 23313 205.70 - Surgical Excision 74611 351.90 23314 240.55 74612 420.75 23315 289.00 74613 495.55 23321 141.10 - Surgical Incision 75112 136.00 23322 191.25 75121 187.85 23323 224.40 76941 359.55 23324 262.65 76949 129.20 23325 314.50 76951 130.90 23411 109.65 76952 261.80 23412 148.75 76959 130.90 23413 174.25 76961 172.55 23414 204.00 77801 272.00 23415 244.80 77802 272.00 23511 129.20 77803 272.00 23512 176.80 TMJ - Appliance Splints * 78701 628.15 23513 205.70 * 78702 628.15 23514 240.55 Oral Surgery 79123 141.10 23515 289.00 79403 97.75 23602 158.10 79404 153.00 Inlays - Metal 25111 361.25 79602 81.60 25112 527.85 Endodontics 33111 450.50 25113 566.10 - Root Canal Therapy 33115 561.00 25114 566.10 33121 626.45 - Composite 25121 413.10 33131 793.05 25122 538.90 33124 790.50 25123 579.70 33134 957.10 25124 579.70 33141 926.50
33125 790.50 43422 69.70 33135 957.10 43423 104.55 33144 1088.85 43424 139.40 33145 1088.85 43425 174.25 33601 130.05 43426 209.10 33602 162.35 43427 17.43 33611 81.60 14611 236.30 33612 90.10 - Appliance * 14612 236.30 - Periapical Services 34111 267.75 * 14621 101.15 34112 356.15 * 14622 202.30 34121 358.70 * 14631 52.70 34122 448.80 * 14711 317.05 34131 423.30 * 14712 317.05 34132 583.95 * 14721 436.05 34141 345.95 * 14722 436.05 34142 415.65 * 14731 101.15 34151 436.90 - Adjustments, Repairs * 14732 202.30 34152 577.15 * 49211 I.c 34161 527.00 42111 192.10 34162 640.90 - Surgical 42201 226.95 34163 765.85 42311 281.35 34211 71.40 42321 306.00 - Retrofilling 34212 119.85 42331 62.90 34221 71.40 42411 819.40 34222 119.85 42421 542.30 34231 71.40 42431 627.30 34232 119.85 42511 516.80 34241 71.40 42521 544.85 34242 119.85 42611 598.40 34251 71.40 42811 230.35 34252 119.85 42819 325.55 34261 71.40 42821 101.15 34262 119.85 42831 101.15 34263 154.70 42832 202.30 43111 62.90 Surgical Services - Miscellaneous 34411 329.80 43211 66.30 34412 398.65 Periodontal Splinting 43221 72.25 34421 248.20 43231 39.10 34422 248.20 43241 66.30 34423 248.20 43281 66.30 34451 264.35 43289 66.30 34452 402.05 16511 101.15 34453 462.40 Occlusal Adjustment 16512 202.30 34521 322.15 16513 303.45 34522 447.10 16514 404.60 34523 511.70 16519 101.15 39201 68.00 73411 481.95 39202 68.00 - Pulpotomy 32221 109.65 32222 144.50 Emergency Treatment for 91121 101.15 32232 72.25 Dental Pain 91122 202.30 - Pulpectomy 32311 126.65 91211 101.15 32312 143.65 91212 202.30 32321 142.80 91213 303.45 - Pulp Capping 20111 93.50 91219 101.15 20119 93.50 91231 101.15 20131 37.40 91232 202.30 20139 37.40 91233 303.45 20141 27.20 91234 404.60 20149 27.20 92411 42.50 Sedative Dressing 20121 121.55 Anesthesia 92412 70.55 20129 121.55 92413 98.60 Emergency Services 39211 79.90 92414 126.65 39212 111.35 92415 154.70 Bleaching - Non Vital 39311 130.90 92431 75.65 39312 261.80 92432 127.50 39313 392.70 92433 179.35 39319 130.90 92434 231.20 Periodontics-Non Surgical 41211 130.05 92435 283.05 41212 260.10 92441 51.85 41221 130.05 92452 178.50 41222 260.10 92453 240.55 41301 58.65 92454 302.60 41302 117.30 92455 364.65 - Root Planing 43421 34.85
* 51601 282.60 Professional Services 93111 130.90 * 51602 307.80 93112 261.80 * 51811 598.20 93119 130.90 * 51812 651.60 94101 57.80 * 51911 859.20 94102 125.80 * 51912 936.60 94301 39.95 * 52101 170.40 94302 56.10 * 52102 170.40 96201 48.45 * 52111 212.40 96202 48.45 * 52112 212.40 99111 I.c. * 52201 212.40 99333 I.c. * 52202 212.40 99555 I.c. * 52211 212.40 Repairs to Existing * 55101 61.20 * 52212 212.40 Dentures * 55102 61.20 * 52301 347.40 * 55201 124.10 * 52302 347.40 * 55202 124.10 * 52311 267.00 * 55301 62.90 * 52312 267.00 * 55302 62.90 * 52401 279.00 * 55401 122.40 * 52402 279.00 * 55402 122.40 * 53101 666.00 Relines and Rebasing of * 56211 198.90 * 53102 666.00 Existing Dentures * 56212 198.90 * 53201 654.00 * 56221 197.20 * 53202 654.00 * 56222 197.20 * 53401 730.20 * 56231 249.90 * 53402 730.20 * 56232 249.90 * 53622 700.80 * 56241 202.30 * 53623 700.80 * 56242 202.30 * 54201 51.60 * 56311 202.30 Denture Adjustments * 54202 103.20 * 56312 202.30 * 54209 51.60 * 56321 202.30 * 54301 303.60 * 56322 202.30 * 54302 303.60 Stainless Steel Crown 22211 164.05 * 55501 42.60 22311 164.05 * 56411 229.20 Recementing Existing 29101 101.15 * 56412 229.20 Inlay or Crown 29102 202.30 * 56511 85.20 29103 303.45 * 56512 85.20 29109 101.15 * 56521 85.20 * 56522 85.20 Note: * Laboratory charges are eligible expenses where * 56601 21.60 applicable. These costs will be reimbursed at 85% under * 56602 178.80 the Basic and Routine sections. * 62101 214.80 ** I.c. will be reimbursed at 85% of dentist charge. Initial Installation or * 62102 214.80 Replacement of Fixed * 62105 I.c. Level III 60% - Major Restorative - Reimbursed at 60% Bridges 62501 214.80 of Dental charges to the maximum indicated below. * 62701 214.80 * 62702 214.80 Plastic Bonding * 27601 371.40 * 62703 214.80 * 27602 371.40 * 62801 159.00 * 23122 164.40 * 63001 71.40 * 27111 381.00 63009 71.40 Initial Installation or * 27121 103.80 66221 71.40 Replacement of Crown * 27201 472.20 66222 142.80 * 27211 472.20 66251 71.40 * 27212 514.80 66252 142.80 * 27301 472.20 66253 214.20 * 27302 514.80 66711 73.20 * 27311 472.20 66719 73.20 * 27312 514.80 66731 217.20 27401 82.20 * 67111 451.80 27409 82.20 67121 87.60 27711 57.60 67131 382.20 27721 91.20 * 67201 451.80 * 25731 120.00 * 67202 492.00 * 25732 144.00 * 67211 451.80 * 25733 165.60 * 67212 492.00 29301 71.40 * 67301 451.80 29302 142.80 * 67311 433.80 Initial Installation or * 51101 598.20 * 67318 100.80 Replacement of Complete * 51102 651.60 * 67321 382.20 or Partial Dentures * 51201 745.80 * 67322 382.20 * 51202 812.40 * 67331 451.80 * 51301 598.20 * 67341 138.00 * 51302 651.60 * 67501 84.00 Rebase complete denture 33117 805.80 Repairs and Recementing * 66111 71.40 Maxillary (upper) 33127 805.80
of Existing Fixed Bridge * 66112 142.80 Mandibular (lower) * 66113 241.20 Maxillary and Mandibular * 66211 71.40 Rebase partial denture * 66212 142.80 Maxillary (upper) 43116 805.80 * 66213 214.20 Mandibular (lower) 43126 805.80 * 66301 71.40 Maxillary and Mandibular * 66302 142.80 * 66303 214.20 Repairs to Existing Dentures * 69301 24.00 * 69302 37.20 Repair, no impression required * 69303 50.40 Complete 36110 94.35 * 69701 70.20 Maxillary (upper) 36120 94.35 * 69702 34.80 Mandibular (lower) Partial 46110 94.35 Note: * Laboratory charges are eligible expenses where Maxillary (upper) 46120 94.35 applicable. These costs will be reimbursed at 60% under Mandibular (lower) the Major Restorative Services. Repair, impression required Complete 36210 127.50 ** I.c. will be reimbursed at 60% of dentist charge. Maxillary (upper) 36220 127.50 Mandibular (lower) 1. Procedure Codes involving the use of gold will be Partial 46210 127.50 covered if no other substitute is deemed suitable. Maxillary (upper) 46220 127.50 Where gold is elective, only the cost of customary Mandibular (lower) substitute will be considered for reimbursement. NOTE: All services include laboratory charges. 2. Placement of crowns, bridges or dentures will be covered if existing appliance is at least five (5) years old and cannot be made serviceable or where necessitated through the removal of additional natural teeth while insured. Major Services - Reimbursed at 60% of Denturists charges to the maximum plan reimbursement. Initial Installation or Replacement Complete Dentures 3. The administrator is authorized to establish liability Maxillary (upper) 31310 891.00 under the plan based on the least expensive benefit if Mandibular (lower) 31320 891.00 it will produce a professionally adequate result. Maxillary and Mandibular Partial Denture, Acrylic Base, Level IV 50% - Orthodontic Services for Audlts and No Clasps (1 tooth) Dependent Children - Maxillary (upper) 41612 789.00 Reimbursed at 50% of dental charges. Mandibular (lower) 41622 826.20 Maxillary and Mandibular Reimbursement is provided at 50% for all reasonable Partial Denture (semi-precision) Metal Base, Cast or and customary charges for orthodontic services for adults Wrought Clasp and Rests (tooth borne) and dependent children of eligible teachers to a lifetime Maxillary (upper) * 41216 1714.80 maximum of $2,000 per individual. Where a teacher Mandibular (lower) * 41226 1714.80 is married to a teacher and both are eligible for dental Maxillary and Mandibular * coverage, the lifetime maximum for each dependent Partial Denture (semi-precision) Metal Base, Cast or will amount to $4,000 per individual. Wrought Clasp and Rests (free end) Maxillary (upper) * 41110 1714.80 DENTURISTS Mandibular (lower) * 41120 1714.80 Routine Service - Reimbursed at 85% of Denturists Maxillary and Mandibular * charges to the maximum plan reimbursement Partial Denture (precision) Metal Base, Cast or Wrought Clasps and Rests (free end) Relines and Rebases to Maxillary (upper) * 41114 1069.80 Existing Dentures Mandibular (lower) * 41124 1069.80 Reline complete denture Wrought Clasps * 71010 86.40 (self polymerizing) Installation of additional tooth or teeth clasps to Maxillary (upper) 32215 425.00 existing dentures (necessitated through removal of Mandibular (lower) 32225 425.00 natural tooth or teeth while insured) Maxillary and Mandibular * 46310 103.20 Reline partial denture * 46320 103.20 (self polymerizing) Maxillary (upper) 42210 425.00 Note: * Casting costs are eligible expenses where Mandibular (lower) 42220 425.00 applicable. These costs will be reimbursed at 60% Maxillary and Mandibular under the Major Services. Reline complete denture (lab processed) 1. Procedures involving the use of gold will be covered Maxillary (upper) 32110 425.00 if no substitute is deemed suitable. Where gold is Mandibular (lower) 32120 425.00 elective, only the cost of customary substitute will be Maxillary and Mandibular considered for reimbursement. Reline partial denture (lab processed) 2. Replacement of dentures will be covered if existing Maxillary (upper) 42116 425.00 appliance is at least five (5) years old and cannot be Mandibular (lower) 42126 425.00 made serviceable, or where necessitated through the Maxillary and Mandibular removal of additional natural teeth while insured.