| A. |
R&C dental fees are those that are usual, customary and reasonable, as those terms are defined below in a., b. and c.
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A "usual" fee is that fee regularly charged and received for a given service by an individual dentist, i.e. his or
her own usual fee. If more than one fee is charged for a given service, the fee determined to be usual shall not exceed the
lowest fee, which is regularly charged, or is offered to patients.
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A fee is "customary" when it is within the range of usual fees charged and received by dentists of similar
training for the same service with the geographic area determined by the carrier to be relevant. A customary fee for a
participating dentist is the fee allowed by the carrier in the Participating Dentist Agreement.
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A fee is "reasonable" if it is "usual" and "customary" or if it falls above "usual" or "customary" or both, but is
determined to be justifiable considering the special circumstances or extraordinary difficulty of the case in question.
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