Allowed amount
The maximum your plan will recognize for a procedure, regardless of what's billed.
What is the allowed amount?
The allowed amount is the maximum fee your PPO carrier will recognize for a given dental procedure when determining how to pay a claim. For in-network dentists, the allowed amount is the contracted negotiated fee, a rate the dentist has agreed to accept as payment in full. For out-of-network dentists, the allowed amount is the UCR (usual, customary, and reasonable) fee, a market-based ceiling the carrier sets based on historical claim data in your geographic area. Coinsurance percentages are applied to the allowed amount, not to the dentist's full billed charge, making it the single most important number in your cost calculation.
| Network status | How the allowed amount is set | Can you be billed above it? |
|---|---|---|
| In-network | Contracted negotiated fee, fixed in advance | No, the excess is written off |
| Out-of-network | UCR ceiling based on area claim data | Yes, the gap is balance billed to you |
How it works
When a claim arrives, the carrier looks up the CDT procedure code and your plan's fee schedule (or UCR table for out-of-network). That lookup produces the allowed amount. The carrier then applies: deductible first (if unmet), then the plan's coinsurance percentage to the remainder. If the dentist charges more than the allowed amount, the excess is either written off (in-network) or billed to you (out-of-network).
Filling (CDT D2392). In-network contracted rate: $180. Out-of-network UCR: $220. Dentist's actual charge: $280. In-network: plan pays 80% × $180 = $144. You pay 20% × $180 = $36. No balance bill. Out-of-network: plan pays 80% × $220 = $176. You pay 20% × $220 = $44 coinsurance + $60 balance bill ($280 − $220) = $104 total.
What to watch out for
- UCR rates are proprietary. Carriers do not publish the methodology or percentile used to set UCR. You can request a pre-determination of benefits to learn your plan's specific UCR for a procedure before treatment, this is your best tool for advance cost planning.
- Allowed amounts vary by geography. The same crown in Manhattan may have an allowed amount of $1,500; the same crown in rural Kansas may be $750. If you travel or see an out-of-area specialist, verify the UCR for that provider's location.
Frequently asked questions about allowed amount
Request a pre-determination of benefits before treatment. Provide your dentist's treatment plan (with CDT codes) to the carrier. The carrier will issue a written estimate showing the allowed amount, your expected coinsurance, and deductible status. This is not a guarantee of payment but is the most accurate advance estimate available.
Within the same network, the contracted fee schedule is typically uniform for a given geographic fee region. However, carriers sometimes have multiple fee schedules (e.g., Delta Dental PPO vs. Delta Dental Premier) with different rates. Confirm which network you're using and which schedule applies.
No. In-network dentists are contractually prohibited from charging patients more than the plan's negotiated fee for covered services. This is the core protection of being in-network. If an in-network dentist bills you above the contracted rate for a covered service, report it to your carrier, it violates their participation agreement.
Your Explanation of Benefits (EOB) shows the allowed amount, not the dentist's full billed charge. The difference between billed and allowed is either written off (in-network) or balanced-billed to you (out-of-network). The EOB columns to focus on are 'amount billed,' 'allowed amount,' 'plan paid,' and 'member responsibility.'
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