INFS vs. UCR — what an out-of-network dentist really costs

1 Pick an area and a service

ZIP code Five digits.

2 Set up the plan

In-network discount % of area average What in-network dentists agreed to accept. 65 % matches the source worksheet ($130 of a $199 average). This sets the INFS amount for every service.

How the UCR percentile is applied % of the area average
The source worksheet’s method: average × 70/80/90 %. True percentile of area charges
The industry definition: the charge level at or below which that share of area dentists bill.

Worth knowing: these two are not the same, and they can point opposite ways. A true 90th percentile sits above the area average, so it usually leaves the member owing little or nothing. “90 % of the average” sits below it, so the member always owes something. Confirm which one a plan actually uses before quoting it.

3 What the member gets billed, by service

Out-of-network dentists don’t have to accept the plan’s payment as payment in full. Most subtract what the plan paid and bill the member the difference. Each cell below is that difference — assuming the dentist charges the area average.

Assume the out-of-network dentist charges the area average the highest charge in the area

Service	Dentist bills	INFS	UCR 70th	UCR 80th	UCR 90th

Cheapest plan Highest exposure to the member out-of-network

Richest plan The higher the UCR percentile, the lower the cost exposure to the member

4 One service, dentist by dentist

Dental charges are not regulated by any government entity — a dentist can charge whatever they choose, which is why the same procedure has a different price at every office. The average of those prices is the UCR figure. Edit any of them.

Dental office	Charge for this service

Average cost in the area $0 This is the “UCR” figure — also called U&C, Usual, Customary & Reasonable.

What the out-of-network dentist actually bills $ Defaults to the area average. Raise it to model an office that charges above the area. Negotiated in-network rate for this service (INFS) $ Derived from the discount above. Override it if you know the real negotiated rate.

? How each one is calculated

INFS — In-Network Fee Schedule

The plan pays the out-of-network dentist only what it negotiated with its in-network dentists.

Plan pays = $130 → Member owes = billed − $130

UCR — Usual, Customary & Reasonable

The plan pays a percentile of what dentists in that area charge. The percentile is set by the plan design.

Plan pays = area average × percentile → Member owes = billed − plan pays

Illustration only. This models the balance-bill exposure alone — deductible, coinsurance, and annual maximum are not applied, so a real member’s cost is higher than what is shown. Actual out-of-network billing depends on the provider and how they choose to bill. Charge figures are a geographic model, not a licensed UCR table.