RFP_26_041-DJ_Appendix H_Dental DPPO Fee and UCR Schedule - draft.xlsx

This is a Dental PPO Fee and UCR Schedule appendix submitted in response to RFP No. 26-041/DJ for Florida's Multiple Option Dental Program. The appendix requires respondents to complete a comprehensive fee schedule detailing their proposed charges for covered dental procedures across multiple service categories, including preventive care (periodic evaluations, prophylaxis, fluoride applications, and sealants), diagnostic imaging (intraoral and panoramic radiographs), restorative services (composite fillings and crowns), endodontic therapy (root canal treatments for anterior, bicuspid, and molar teeth), periodontal services (scaling, root planing, and maintenance), surgical extractions (simple and impacted tooth removal), implant procedures (placement, abutments, and maintenance), and prosthodontic services (complete and partial dentures). The schedule specifically requires respondents to enter their quoted plan's submitted charge per covered procedure in the designated columns, excluding allowed charges, with notation of "N/A" for non-applicable services.

The fee schedule is organized by ADA Code and includes columns for DPPO (Dental Preferred Provider Organization) fees and both 80th and 90th percentile UCR (Usual, Customary, and Reasonable) submitted rates, with all fields currently populated at $0.00 pending respondent completion. ZIP Code 334 is referenced in the document header, indicating the schedule may be specific to a particular geographic service area. This appendix serves as a critical component of the bidding process, allowing the state to evaluate and compare the cost structure of different dental plan options being proposed by respondents for employee or beneficiary coverage under the Multiple Option Dental Program.