Fee for Service Practices

General Information

How many active patients does your practice currently have?

How long have you been in practice?

Are there other providers in your practice?

If there are other providers in your practice, how many and what are their specialties?

Fee Details

Please provide your practice's Usual, Customary, and Reasonable (UCR) fees for the following procedure: D0120 (Periodic oral evaluation)

Please provide your practice's Usual, Customary, and Reasonable (UCR) fees for the following procedure: D1110 (Prophylaxis - adult)

Please provide your practice's Usual, Customary, and Reasonable (UCR) fees for the following procedure: D2740 (Crown - porcelain/ceramic substrate)

Network Participation

What are your main motivations for considering joining a dental network? (Please select all that apply.)

Increase patient volume

Competitive market pressures

Recommendations from peers

Other

Please specify which networks and your reason for reverting to a fee-for-service model.

Feedback & Expectations

What reservations or concerns do you have about joining a dental network?

How did you hear about our consultancy services, and what are your expectations in terms of support and guidance?

Please share any other relevant details or questions you might have about transitioning from a fee-for-service model to a network-based practice

Contact Information

Practice's Name

Practice's Website

Your role

State your practice is located

Contact Information - Continued

First Name

Last Name

Email *

Phone *

Your time zone?

Preferred Time and Method of Contact