Procedure Code Pricing

Procedure Code Pricing Results

Select Member

{{item.memberProfile.personName.firstName}} {{item.memberProfile.personName.middleName}} {{item.memberProfile.personName.lastName}}

All Results for:

Member Name: {{resultMemberInfo.memberProfile.personName.firstName}} {{resultMemberInfo.memberProfile.personName.lastName}}

Dentist Name: {{dentistData.providerName.firstName}} {{dentistData.providerName.lastName}}

Date: {{pcpsearchobj.searchDate | date :'MM/dd/yyyy'}}

Location: {{pcpsearchobj.providerAddress.addressLine1}},
{{pcpsearchobj.providerAddress.city | uppercase}} {{pcpsearchobj.providerAddress.state | uppercase}}, {{pcpsearchobj.providerAddress.zip5}}

Procedure Code: {{pcpActiveList.procedureCode.codeValue}}

Pricing Result- In Network View Fee Schedule

The member is responsible for {{pcpActiveList.discountPercent}} of allowed amount.

NOTE: An alternate benefit applies to Procedure Code {{pcpActiveList.procedureCode.codeValue}}. This procedure has been alternated to Procedure {{pcpActiveList.alternateProcedureCode}} which the pricing below reflects. The member will be responsible for the difference between the Original Plan Priced Amount $ {{pcpActiveList.planAmount.planPricedAmount}} and the Alternate Benefit Plan priced amount $ {{pcpActiveList.planAmount.alternateBenefitPriceAmount}} in addition to any co-insurance and co-payments. Member and Provider should discuss treatment options since an alternate benefit applies.

Procedure Code:	{{pcpActiveList.procedureCode.codeValue}}	{{pcpActiveList.alternateProcedureCode}}
Dental Procedure Description:	{{pcpActiveList.procedureCode.codeDesc \| uppercase}}	{{altExp \| uppercase}}
Member Copayment Amount:	{{errCoverage}}	{{pcpActiveList.memberAmount.inNetwork.copayAmount}}	{{pcpActiveList.memberAmount.outOfNetwork.copayAmount}}
Member Coinsurance Percentage:	{{errCoverage}}	{{pcpActiveList.memberAmount.inNetwork.coinsurancePercentage}}	{{pcpActiveList.memberAmount.outOfNetwork.coinsurancePercentage}}
Member Coinsurance Amount:	{{errCoverage}}	{{pcpActiveList.memberAmount.inNetwork.coinsuranceAmount}}	{{pcpActiveList.memberAmount.outOfNetwork.coinsuranceAmount}}
Plan Coinsurance Percentage:	{{errCoverage}}	{{pcpActiveList.planAmount.inNetwork.coinsurancePercentage}}	{{pcpActiveList.planAmount.outOfNetwork.coinsurancePercentage}}
Plan Priced Amount:	{{errCoverage}}	{{pcpActiveList.planAmount.inNetwork.coinsuranceAmount}}
Plan Pay Amount:	{{errCoverage}}	{{pcpActiveList.planAmount.inNetwork.coinsuranceAmount}}
Agreement Number:	{{errCoverage}}	{{pcpActiveList.deductibleAmount.outOfNetwork.indicator}}
Compensation Description :	{{errCoverage}}	{{pcpActiveList.networkCompensationDescription}}	{{pcpActiveList.networkCompensationDescription}}
Warning Text:	{{pcpActiveList.userMessage.codeDesc}}

Plan Year Beginning:	{{errCoverage}}	{{pcpsearchobj.plan.planBeginYear}}
Frequency Limitations:	{{errCoverage}}	{{freqLimit}}
Age Limitations:	{{errCoverage}}	{{ageLimit}}
Waiting Period:	{{errCoverage}}	{{pcpActiveList.limitsAndFrequency.waitingPeriodIndicator}}
Length of Waiting Period:	{{errCoverage}}	{{pcpActiveList.limitsAndFrequency.waitingPeriodLength}}
Expected Satisfied Date:	{{errCoverage}}	{{pcpActiveList.limitsAndFrequency.waitingPeriodLength}}
Network Deductible:	{{errCoverage}}	{{pcpActiveList.deductibleAmount.inNetwork.indicator}}	{{pcpActiveList.deductibleAmount.outOfNetwork.indicator}}
Network Deductible Individual:	{{errCoverage}}	{{pcpActiveList.deductibleAmount.inNetwork.individualAmount}}	{{pcpActiveList.deductibleAmount.outOfNetwork.individualAmount}}
Network Deductible Family:	{{errCoverage}}	{{pcpActiveList.deductibleAmount.inNetwork.familyAmount}}	{{pcpActiveList.deductibleAmount.outOfNetwork.familyAmount}}
Network Deductible Amount Remaining Individual:	{{errCoverage}}	{{pcpActiveList.deductibleAmount.inNetwork.individualRemainingAmount}}	{{pcpActiveList.deductibleAmount.outOfNetwork.individualRemainingAmount}}
Network Deductible Amount Remaining Family:	{{errCoverage}}	{{pcpActiveList.deductibleAmount.inNetwork.familyRemainingAmount}}	{{pcpActiveList.deductibleAmount.outOfNetwork.familyRemainingAmount}}
Utilization Rule:	{{utilRule}} View Utilization Rules

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.