What usual, customary and reasonable fee (UCR) means
Usual, customary and reasonable is the fee level an indemnity or out-of-network claim is measured against, set by the plan and not by the dentist.
Why the term matters
How it changes the treatment conversation
If the dentist charges more than the plan's amount, the difference is usually yours, which is why identical coverage can pay differently.
Ask this
A question that makes the term useful
“What amount does the plan recognize for these procedure codes, and how does it set it?”
Full explanation
In depth
Usual, customary and reasonable, usually shortened to UCR, is the fee level an indemnity or out-of-network claim is measured against. Cigna and MetLife describe indemnity plans as reimbursing covered services up to what the plan considers usual, customary and reasonable. The plan, not the dentist, decides what that amount is, so it can be lower than the fee on your bill, and the difference is yours. That is why two people with the same treatment and the same percentage coverage can receive different payments. The term is a plan concept, not a legal price, and it is not a promise about what any dentist charges. Plans may also revise their amounts over time. This entry explains where the amount comes from, how it differs from a network's negotiated fee and what to ask so you can predict your share before treatment.
Also called: UCR, usual and customary fee, U and C, reasonable and customary, customary fee, prevailing fee.
How it works
What UCR means in practice
| Factor | Detail |
|---|---|
| Set by the plan | Cigna says an indemnity plan pays up to what it considers usual, customary and reasonable. MetLife says the plan determines a UCR fee for the service you require. |
| Not the dentist's bill | If the dentist charges more than the plan's UCR amount, the difference is usually yours to pay. |
| Different from a negotiated fee | A PPO network fee is agreed by contract, and a UCR amount is set by the plan for services outside a network. Network dentists accept the negotiated fee as payment in full for covered services, apart from your share. |
| Varies by plan | Different plans set their UCR levels differently, so the same fee can be paid differently by different plans. |
Ask each plan how it sets its usual and customary level and how often it updates it.
Predicting your share
How to estimate what you will owe
- Ask the dental office for the fee it will charge for each procedure code
- Ask the plan what UCR amount it recognizes for the same codes
- Apply your deductible and coinsurance to the plan's amount
- Add the difference between the dentist's fee and the plan's amount, which is yours
- Ask for a pretreatment estimate to confirm
Watch for
Where surprises come from
A dentist whose fees are above the plan's UCR level, so the difference is billed to you
Assuming your coinsurance percentage applies to the dentist's fee and not to the plan's amount
Comparing two offices by fee alone, without checking what your plan would recognize
Assuming the amount is fixed. Plans may revise it.
Questions people ask
Common questions
01What does usual, customary and reasonable mean?
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It is the fee an indemnity or out-of-network claim is measured against. Cigna and MetLife describe indemnity plans as reimbursing up to what the plan considers usual, customary and reasonable for a service. The plan determines the amount. If your dentist charges more, the difference is usually yours.
02Who decides what is usual and customary?
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The plan does. MetLife says the plan determines a usual, customary or reasonable fee for the service. Ask the plan how it sets the amount and how often it updates it. Different plans can recognize different amounts for the same procedure.
03Why did my plan pay less than I expected?
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It may have applied its recognized amount and not your dentist's fee, then applied the deductible and coinsurance. Check the explanation of benefits for the allowed amount, and ask the plan to explain each line. An out-of-network dentist may bill the difference.
04Is the UCR amount the same as the allowed amount?
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They are related. The allowed amount is the fee the plan recognizes for a claim, and for indemnity and out-of-network claims it is often set by the plan's usual and customary level. For network dentists, it is the negotiated fee. See the glossary entry on the allowed amount.
05Can I negotiate with my dentist if the plan pays less?
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You can ask about the fee, payment terms and any self-pay or discount options. A network dentist has agreed to the plan's fee for covered services. An out-of-network dentist has not. Ask the office before treatment, and get any arrangement in writing.
06Does UCR apply to network dentists?
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Generally not. MetLife says participating dentists accept negotiated fees as payment in full for covered services, so the negotiated fee applies. UCR matters for indemnity plans and for out-of-network care. Check with your plan how it treats each case.
07How can I find out the plan's amount before treatment?
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Ask the office to submit a pretreatment estimate, and ask the plan what amount it recognizes for each code. MetLife says an explanation of benefits describes what it will cover, and that actual payments may vary once limits apply. Compare it with the office's quote.
08Does UCR change over time?
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It can. Plans may update their recognized amounts, so the same procedure could be paid differently later. Ask the plan when its levels were last set and how it revises them. Check again before major treatment.
09Is a PPO different from a UCR plan?
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Yes. A PPO has a network with negotiated fees, and an indemnity plan pays by UCR with no network. Cigna and MetLife describe the difference. On a PPO, out-of-network care can also be measured against a plan amount, so check how yours pays.
10Can a dentist bill me above UCR?
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An out-of-network dentist may, and the difference is usually yours. A network dentist has agreed to the plan's fee for covered services. Ask the office whether it will accept the plan's amount as payment in full, and get the answer in writing.
11Is UCR the same as the market price for a procedure?
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Not necessarily. It is the plan's own measure, and it may be higher or lower than what offices charge locally. Compare a written estimate with the plan's amount, and compare more than one office.
12How does UCR affect orthodontics and implants?
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The same principle applies wherever a plan reimburses by its own recognized amount. The plan pays a share of that amount up to its limits, and you cover the rest. Ask about the amount for the specific codes, and about any lifetime maximum.
Related glossary terms
Sources
- Types of Dental InsuranceCigna HealthcareAccessed 2026-09-24
- What Is a Dental PPO Plan?MetLife Oral Fitness LibraryAccessed 2026-09-24