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2016 Dental Fee ScheduleIf you use an out–of–network (non–PPO) dentist, the Trust will pay the amountindicated in the second (2nd) column of the fee schedule regardless of how muchyour out-of-network dentist charges for the services. You will be responsible for allcharges over and above that amount. After you have met the annual planmaximum, you will be responsible for all charges incurred for the remainder of theyear.Listed fees do not guarantee coverage. Covered services are determined by theSummary Plan Document. Please refer to the Teachers Health Trust Plan Documentavailable on this website for covered benefits. You can also contact the TeachersHealth Trust Service Department for more information on covered services.The out–of–network dental fee schedule, effective as of January 1, 2016, isdisplayed below.2016 Non-PPO Dental Fee ScheduleADA Code What the Trust Will PayD0120 30.00D0140 26.88D0145 34.00D0150 42.00D0160 42.24D0170 26.24D0171 14.72D0180 26.24D0190 10.88D0191 14.72D0210 68.00D0220 18.00D0230 15.00D0240 21.00D0250 28.00D0251 23.00D0260 22.00D0270 21.00D0272 28.00D0273 33.00D0274 37.00D0277 62.00D0290 76.00
D0417D0418D0425D0431D0460D0470D0472D0473D0474D0480 92.00 252.80 172.00 63.00 59.00 28.00 177.28 259.20 259.20 193.92 193.92 193.92 193.92 193.92 193.92 193.92 193.92 132.96 132.96 132.96 132.96 132.96 132.96 132.96 28.16 177.28 177.28 177.28 14.72 22.40 37.12 89.60 10.24 19.20 16.00 33.92 21.76 58.24 58.24 58.24
D2391D2392D2393D2394D2410D2420D2430D2510D2520D2530 60.80 65.92 21.12 21.12 21.12 66.00 46.00 23.00 16.00 23.00 23.00 33.00 78.00 25.00 30.72 110.08 144.00 135.04 201.60 24.96 25.60 48.64 60.16 70.40 72.96 57.60 64.64 75.52 93.44 109.92 57.60 78.72 93.44 108.80 159.36 199.20 242.40 156.96 204.96 227.52
D2792D2794D2799D2910D2915D2920D2921D2929D2930D2931 181.44 238.08 269.76 206.88 259.68 287.04 271.20 285.12 317.28 179.52 211.68 232.32 183.84 231.36 238.08 118.08 309.60 315.84 300.48 304.80 330.72 322.08 286.08 311.04 309.60 277.44 304.32 319.68 322.08 283.68 303.84 297.60 53.76 41.60 35.84 35.84 36.00 75.84 71.04 84.00
D3333D3346D3347D3348D3351D3352D3353D3354D3355D3356 82.56 93.60 94.56 41.60 41.60 22.40 65.76 25.60 102.24 48.00 87.36 66.24 32.64 71.04 75.36 79.20 71.52 49.92 23.04 21.76 66.56 40.96 67.20 85.76 89.60 268.80 332.80 416.00 117.12 132.48 76.80 323.20 420.48 456.96 144.00 88.32 207.36 203.52 101.12 51.20
D4265D4266D4267D4268D4270D4271D4273D4274D4275D4276 51.20 222.72 277.76 291.20 112.00 129.60 106.56 106.56 79.36 55.20 119.52 131.20 325.44 220.80 42.88 136.96 60.80 146.40 72.48 24.96 90.24 79.20 198.24 98.88 125.76 220.80 306.72 154.56 104.16 102.72 52.32 151.20 158.40 94.08 224.64 225.60 359.04 79.20 215.52 359.04
D5421D5422D5510D5520D5610D5620D5630D5640D5650D5660 184.32 92.64 174.24 108.00 134.40 124.16 103.04 51.84 53.76 58.88 51.84 25.60 16.80 434.88 434.88 465.12 465.12 331.68 331.68 485.76 485.76 324.00 324.00 468.00 468.00 547.68 547.68 216.96 27.84 27.84 25.92 25.92 49.44 42.72 49.92 63.84 60.48 44.64 62.88 69.60
D6012D6013D6040D6050D6051D6052D6053D6054D6055D6056 311.04 311.04 152.16 152.16 133.44 133.44 88.32 88.32 76.32 76.32 105.60 105.60 104.16 104.16 197.28 197.28 164.64 164.64 37.92 37.92 468.96 468.96 448.32 470.40 448.32 470.40 43.20 211.68 702.24 480.00 120.00 445.44 2,093.28 1,462.56 65.28 65.76 455.52 455.52 524.16 136.80
D6100D6101D6102D6103D6104D6110D6111D6112D6113D6114 237.60 343.20 342.24 304.32 336.48 341.28 303.84 333.12 408.00 394.56 378.24 346.56 343.20 295.20 325.44 336.48 306.24 332.16 408.00 407.04 381.12 601.44 560.16 28.32 193.92 201.60 37.12 53.76 337.44 199.04 156.96 72.00 157.44 104.64 168.96 465.60 465.60 465.60 465.60 542.88
D6610D6611D6612D6613D6614D6615D6624D6634D6710D6720 542.88 542.88 542.88 336.48 309.60 322.08 283.68 303.84 297.60 318.72 283.68 304.80 327.84 315.84 300.48 304.80 53.76 160.80 232.80 81.12 267.36 290.40 224.64 244.80 193.92 213.60 202.56 229.92 314.88 306.72 246.72 270.24 213.12 264.48 225.12 244.32 216.48 237.12 309.60 315.84
D7240D7241D7250D7251D7260D7261D7270D7272D7280D7282 300.48 304.80 327.84 318.72 278.40 304.80 333.60 302.40 328.32 316.80 322.08 280.80 303.84 53.76 303.84 228.96 53.76 85.92 79.20 62.88 165.60 118.56 29.28 142.08 197.28 51.84 53.12 82.56 101.12 124.16 144.64 161.92 83.84 56.64 108.00 110.88 158.72 159.36 123.52 119.68
D7471D7472D7473D7485D7490D7510D7511D7520D7521D7530 49.92 141.44 57.60 28.16 41.60 104.32 105.60 613.92 563.52 188.64 172.80 81.92 58.88 107.52 76.80 446.88 768.96 52.32 129.60 132.48 142.08 163.68 166.56 142.08 166.56 83.04 117.12 61.44 68.64 67.20 58.08 58.56 57.60 85.92 3,040.32 75.52 94.08 75.52 94.08 33.12
D8660D8670D8680D8681D8691D8692D8693D8694D9110D9120 67.68 96.96 242.00 28.32 60.00 49.28 44.16 52.80 104.64 1,036.80 600.00 168.00 119.52 124.80 64.80 77.76 358.08 12.48 379.52 677.60 800.80 1,078.40 1,000.00 893.00 1,000.00 1,000.00 1,000.00 1,000.00 147.84 252.00 96.00 102.40 274.40 61.60 110.40 76.80 57.60 36.00 44.16 42.88
D9950D9951D9952 23.04 19.84 73.60 13.44 28.80 114.56 69.76 54.40 20.48 89.60 44.80 41.60 105.60 44.80 82.56 67.84 30.08 49.28 23.68 41.60 21.76 21.76 40.32 33.92 33.92 33.92 33.92 154.24 76.80 48.64 56.96 51.84 144.00
The out-of-network dental fee schedule, effective as of January 1, 2016, is displayed below. 2016 Non-PPO Dental Fee Schedule ADA Code What the Trust Will Pay D0120 30.00 D0140 26.88 D0145 34.00 D0150 42.00 D0160 42.24 D0170 26.24 D0171 14.72 D0180 26.24 D0190 10.88 D0191 14.72 D0210 68.00 D0220 18.00 D0230 15.00
