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

This is a Dental PPO Fee and UCR Schedule appendix (Appendix H) submitted as part of RFP No. 26-041/DJ for Florida's Multiple Option Dental Program. The document serves as a template for respondents to submit their proposed fee schedules and Usual, Customary, and Reasonable (UCR) charges for covered dental procedures. The appendix requires bidders to complete a comprehensive chart detailing their quoted plan's submitted charges per covered procedure across multiple service categories, including preventive care (oral evaluations, prophylaxis, radiographic imaging, fluoride applications, and sealants), restorative procedures (composite fillings and core buildups), prosthodontic services (crowns and dentures), endodontic therapy (root canal treatments), periodontal services (scaling, root planing, and maintenance), oral surgery (extractions and tooth removals), and dental implant procedures (placement, abutments, and maintenance). The schedule covers approximately 50 distinct dental procedure codes identified by their ADA D-codes.

Respondents must enter their organization name and complete the fee schedule for ZIP code area 334, providing DPPO fees, 80th percentile UCR submissions, and 90th percentile UCR submissions for each procedure, or marking entries as "N/A" if applicable. The document explicitly instructs bidders to include their quoted plan's submitted charge per covered procedure without including the allowed charge. This appendix is confidential and proprietary and represents a critical component of the bidder's proposal, as it establishes the pricing framework that will determine the competitiveness and value proposition of their dental plan offering to the state of Florida.