Fee Schedule Search Results
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Member Information:
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Practitioner Information:
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Unless required by applicable law, verification of benefits or eligibility is not an authorization or guarantee of payment. Payment can only be made after the claim has been received and reviewed in regards to eligibility, benefits, dental necessity, outstanding deductibles and maximums as well as other plan limitations and or exclusions. If differences exist between the information displayed here and your Certificate of Coverage, the Certificate will govern. All terms and conditions are subject to applicable state and federal laws.
Please refer to the last page of the fee schedule for important footnotes if applicable to your plan. Listed rates are plan payment only and exclude member responsibility. Please review coverage and deductible to determine member responsibility.
| Procedure Code | Dental Procedure Description | $Member Co-Pay Amount | Member Pay amount | Member Co Insurance % | Plan Pay Amount | Plan Payment | Plan Payment* |
|---|---|---|---|---|---|---|
| {{finalFeeScheduleColletion[0].reportCodeDis}} | ||||||
| {{oneFeeDis.procedureCode.codeValue}} | {{oneFeeDis.procedureCode.codeDesc}} | $ {{oneFeeDis.memberCopayAmount}} | $ {{oneFeeDis.memberResponsibility}} | {{oneFeeDis.memberCoinsurancePercentage}} % | $ {{oneFeeDis.planRate}} | $ {{oneFeeDis.totalCompensationAmount}} |
| {{finalFeeScheduleColletion[1].reportCodeDis}} | ||||||
| {{oneFeeDis.procedureCode.codeValue}} | {{oneFeeDis.procedureCode.codeDesc}} | $ {{oneFeeDis.memberCopayAmount}} | $ {{oneFeeDis.memberResponsibility}} | {{oneFeeDis.memberCoinsurancePercentage}} % | $ {{oneFeeDis.planRate}} | ${{oneFeeDis.totalCompensationAmount}} |
| {{finalFeeScheduleColletion[2].reportCodeDis}} | ||||||
| {{oneFeeDis.procedureCode.codeValue}} | {{oneFeeDis.procedureCode.codeDesc}} | $ {{oneFeeDis.memberCopayAmount}} | $ {{oneFeeDis.memberResponsibility}} | {{oneFeeDis.memberCoinsurancePercentage}} % | $ {{oneFeeDis.planRate}} | ${{oneFeeDis.totalCompensationAmount}} |
| {{finalFeeScheduleColletion[3].reportCodeDis}} | ||||||
| {{oneFeeDis.procedureCode.codeValue}} | {{oneFeeDis.procedureCode.codeDesc}} | $ {{oneFeeDis.memberCopayAmount}} | $ {{oneFeeDis.memberResponsibility}} | {{oneFeeDis.memberCoinsurancePercentage}} % | $ {{oneFeeDis.planRate}} | $ {{oneFeeDis.totalCompensationAmount}} |
| {{finalFeeScheduleColletion[4].reportCodeDis}} | ||||||
| {{oneFeeDis.procedureCode.codeValue}} | {{oneFeeDis.procedureCode.codeDesc}} | ${{oneFeeDis.memberCopayAmount}} | $ {{oneFeeDis.memberResponsibility}} | {{oneFeeDis.memberCoinsurancePercentage}} % | $ {{oneFeeDis.planRate}} | ${{oneFeeDis.totalCompensationAmount}} |
| {{finalFeeScheduleColletion[5].reportCodeDis}} | ||||||
| {{oneFeeDis.procedureCode.codeValue}} | {{oneFeeDis.procedureCode.codeDesc}} | $ {{oneFeeDis.memberCopayAmount}} | $ {{oneFeeDis.memberResponsibility}} | {{oneFeeDis.memberCoinsurancePercentage}} % | $ {{oneFeeDis.planRate}} | ${{oneFeeDis.totalCompensationAmount}} |
| {{finalFeeScheduleColletion[6].reportCodeDis}} | ||||||
| {{oneFeeDis.procedureCode.codeValue}} | {{oneFeeDis.procedureCode.codeDesc}} | $ {{oneFeeDis.memberCopayAmount}} | $ {{oneFeeDis.memberResponsibility}} | {{oneFeeDis.memberCoinsurancePercentage}} % | $ {{oneFeeDis.planRate}} | $ {{oneFeeDis.totalCompensationAmount}} |
| {{finalFeeScheduleColletion[7].reportCodeDis}} | ||||||
| {{oneFeeDis.procedureCode.codeValue}} | {{oneFeeDis.procedureCode.codeDesc}} | $ {{oneFeeDis.memberCopayAmount}} | $ {{oneFeeDis.memberResponsibility}} | {{oneFeeDis.memberCoinsurancePercentage}} % | $ {{oneFeeDis.planRate}} | $ {{oneFeeDis.totalCompensationAmount}} |
| {{finalFeeScheduleColletion[8].reportCodeDis}} | ||||||
| {{oneFeeDis.procedureCode.codeValue}} | {{oneFeeDis.procedureCode.codeDesc}} | $ {{oneFeeDis.memberCopayAmount}} | $ {{oneFeeDis.memberResponsibility}} | {{oneFeeDis.memberCoinsurancePercentage}} % | $ {{oneFeeDis.planRate}} | ${{oneFeeDis.totalCompensationAmount}} |
| {{finalFeeScheduleColletion[9].reportCodeDis}} | ||||||
| {{oneFeeDis.procedureCode.codeValue}} | {{oneFeeDis.procedureCode.codeDesc}} | $ {{oneFeeDis.memberCopayAmount}} | $ {{oneFeeDis.memberResponsibility}} | {{oneFeeDis.memberCoinsurancePercentage}} % | $ {{oneFeeDis.planRate}} | ${{oneFeeDis.totalCompensationAmount}} |
| {{finalFeeScheduleColletion[10].reportCodeDis}} | ||||||
| {{oneFeeDis.procedureCode.codeValue}} | {{oneFeeDis.procedureCode.codeDesc}} | $ {{oneFeeDis.memberCopayAmount}} | $ {{oneFeeDis.memberResponsibility}} | {{oneFeeDis.memberCoinsurancePercentage}} % | $ {{oneFeeDis.planRate}} | ${{oneFeeDis.totalCompensationAmount}} |
| {{finalFeeScheduleColletion[11].reportCodeDis}} | ||||||
| {{oneFeeDis.procedureCode.codeValue}} | {{oneFeeDis.procedureCode.codeDesc}} | $ {{oneFeeDis.memberCopayAmount}} | $ {{oneFeeDis.memberResponsibility}} | {{oneFeeDis.memberCoinsurancePercentage}} % | $ {{oneFeeDis.planRate}} | $ {{oneFeeDis.totalCompensationAmount}} |
| {{finalFeeScheduleColletion[12].reportCodeDis}} | ||||||
| {{oneFeeDis.procedureCode.codeValue}} | {{oneFeeDis.procedureCode.codeDesc}} | ${{oneFeeDis.memberCopayAmount}} | $ {{oneFeeDis.memberResponsibility}} | {{oneFeeDis.memberCoinsurancePercentage}} % | $ {{oneFeeDis.planRate}} | ${{oneFeeDis.totalCompensationAmount}} |
* The notation "Paid Under Capitation" indicates that the procedure code is fully capitated and covered under capitation. No additional payments are due from the patient or the plan for this particular procedure. Total Compensation= the total amount the practitioner will receive combining all patient and plan payments.
NB = No Benefit
BR = By Report: Benefit determination requires submission of additional information: affected area, performed procedure description, and rationale for procedure with appropriate diagnostic documentation.
† - An alternate benefit has been applied to this procedure. Member and provider should discuss treatment options since an alternate benefit applies. ERR: Indicates we are unable to obtain pricing for this procedure code please contact 866-375-3255
BR = By Report: Benefit determination requires submission of additional information: affected area, performed procedure description, and rationale for procedure with appropriate diagnostic documentation.
† - An alternate benefit has been applied to this procedure. Member and provider should discuss treatment options since an alternate benefit applies. ERR: Indicates we are unable to obtain pricing for this procedure code please contact 866-375-3255
Date Printed: {{ currFeeDate | date:'MM/dd/yyyy' }}
{{procCodeCount}} Procedures Covered
All Benefits
Current Dental Terminology @ American Dental Association