Fee Schedule Search Results
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Member Information:
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Practitioner Information:
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{{proData.providerAddress.city | uppercase}} {{proData.providerAddress.state | uppercase}} {{proData.providerAddress.zip5}}
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| $Member Co-Pay Amount | Member Pay amount | Member Co Insurance % | Plan Pay Amount | * | ||
|---|---|---|---|---|---|---|
| {{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