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<br />~ ~--~~ ~---~- <br /> <br />-- <br /> <br />---- ---------- <br />n_____~ <br />- ---~ - ------ <br /> <br />1.10 "Fee Actually Charged" means the fee for a particular dental service or <br />procedure which a Dentist submits to Delta on an Attending Dentist's <br />Statement, less any portion of such fee which is discounted, waived, or <br />rebated, or which the Dentist does not use good faith efforts to collect. <br /> <br />1.11 <br /> <br />1.12 <br /> <br />1.13 <br /> <br />1.14 <br /> <br />1.15 <br /> <br />1.16 <br /> <br />"Participating Dentist" means a Dentist who has signed an agreement with <br />Delta, agreeing to provide services under the terms and conditions <br />established by Delta. <br /> <br />"Patient Copayment" means the portion of the Dentist's fees or allowances <br />charged for Benefits which is the Eligible Person's responsibility. <br /> <br />"Prevailing Fee" is the fee for a Single Procedure which satisfies the <br />majority of Dentists in California, as determined by Delta based upon <br />confidential fee listings accepted by Delta from Participating Dentists. <br /> <br />"Procedure Numbers" means the Procedure Numbers shown on <br />Appendix B. <br /> <br />"Single Procedure" means a dental procedure listed in Appendix B to which <br />Delta has assigned a separate Procedure Number, ~, a three-surface <br />amalgam restoration of a single permanent tooth (Procedure 02160) or a <br />complete upper denture, including adjustments for a six month period <br />following installation (procedure 05110). <br /> <br />For a Dentist who has signed a Participating Dentist Agreement with Delta, <br />his or her "Usual, Customary, and Reasonable Fee" for any Single <br />Procedure is the fee which the Dentist has filed with Delta and which Delta <br />has accepted. For these dentists, the words "Usual, Customary and <br />Reasonable" mean the following: <br /> <br />USUAL -- A usual fee is the amount which a Dentist regularly charges and <br />receives for a given service. If the Dentist charges more than one fee for <br />a given service, the "usual" fee for that service is the lowest fee which the <br />Dentist regularly charges or offers to patients. <br /> <br />CUSTOMARY -- A fee is customary when it is within the range of usual <br />fees charged and received for a particular service by Dentists of similar <br />training in the same geographic area which Delta determines is statistically <br />relevant. <br /> <br />3 <br /> <br />~___un <br />