Billing · Updated 2026-09-08 · 6 min read

What percentile does an out-of-network dental plan pay at?

Out-of-network allowances are often a percentile of area charges chosen by the employer — and the carrier will not tell you in advance what it comes to.

There is no carrier-wide answer, because the percentile is bought by the employer along with the rest of the plan. Delta's non-participating allowances are often a percentile of a market fee schedule anywhere from the 50th to the 90th; Cigna's maximum reimbursable charge has been observed at the 80th, 85th and 90th on different plans; MetLife's federal plan used the 80th on its High Option in its 2021 brochure. And the reason nobody tells you is not obstruction but design — the basis is a per-plan purchase, and Delta tells the employers buying it that Delta itself "can't predict enrollees' out-of-pocket costs when they go out of network". Meanwhile, 64.2% of out-of-network claim lines we measured in the twelve months to August 2026 came back allowed at the fee the office billed, so the remittances an office would use to work the number out are mostly its own fee reflected back.

What we measured

Paid dental claim lines across the practices we serve, aggregated so no practice, patient or employer group is identifiable. Together these say that reverse-engineering a percentile from your own remittances is close to hopeless: two out-of-network lines in three carry your fee rather than the plan's ceiling, one paid line in eight prints no allowance at all, and a single observation misses the stable answer by a median 16.5%.

What the carriers' own documents say

Delta explains the mechanism to brokers:

"Percentiles are calculated by ranking a set of given fees from lowest to highest. On a list of 10 given fees, the eighth ranked fee would be considered the 80th percentile. There isn't a set amount of space between percentiles, meaning that some percentiles may have the same fees."

"At the 80th percentile, 80% of dentists' fees are paid as billed. Dentists whose fees are above this percentile are charging more than most dentists in their market."

— Delta Dental, out-of-network reimbursement post, Insider Update, August 16 2022.

And then closes the door on looking it up:

"Reimbursement for non–Delta Dental dentists varies by plan. Paying non–Delta Dental dentists based on the 80th percentile or above is considered high reimbursement."

"Delta Dental can't predict enrollees' out-of-pocket costs when they go out of network."

— the same post. The out-of-network basis is a per-plan purchase, and that last line is the carrier's own statement that the lookup an office wants does not exist.

MetLife's federal brochure is the one place a percentile is stated in public with its arithmetic attached, and it is the High Option's basis:

"We use the 80th percentile charge to establish a customary allowance… An example of how the 80th percentile is calculated is to assume one hundred (100) charges for the same service are contained in MetLife's Usual and Customary charge records. These one hundred (100) charges would be sorted from lowest to highest charged amount and numbered 1 through 100. The 80th percentile of charges is the charge that is greater than or equal to the [charge] numbered 80."

— The MetLife Federal Dental Plan 2021 brochure. By the 2026 brochure that programme had stopped using a percentile at all: "The Plan Allowance for Out-of-Network services will be equal to the In-Network Plan Allowance for the covered service."

Some carriers name an outside benchmark rather than their own claim history. A Nevada commercial PPO pays "the lesser of the submitted charge or the Regional Usual & Customary Rate as defined by the 80th percentile of MDR (Medical Data Research) fee [schedule] published by FAIR Health" — Liberty Dental Plan of Nevada Elite PPO Benefit Plan Summary. The 2026 BCBS FEP Dental brochure names the same organisation and gives no percentile at all. Do not assume it is the 80th; the brochure does not say.

What a percentile does to a bill, in Delta's own illustrative numbers: a $1,000 fee at a non-Delta dentist, with the plan's out-of-network allowance at the 90th percentile of $925, has the plan paying 50% of $925 — $463 — and the member paying $538. The same procedure at a PPO contracted fee of $600 at 50% coverage leaves the member owing $300.

Why it depends on the plan

The percentile is a line item in the employer's purchase, sitting beside the annual maximum and the coinsurance. A carrier can offer the same network with a 50th-percentile out-of-network allowance to one employer and a 90th to another, and neither is the carrier's "policy". This is why a percentile learned from one patient's claim is worth nothing on the next patient's, even with the same carrier and the same procedure.

The method varies too, not only the number. Blue Shield of California states that its out-of-network "reimbursement[ ]schedule is an MAC (Maximum Allowable Charge) schedule… the same MAC schedule as our small business dental PPO MAC plans", and Cigna prices out-of-network care on its retail products off "a basic Advantage fee schedule within a specified area". So the first question is not which percentile — it is whether there is a percentile at all.

What to do

• Ask the method first: percentile of area charges, a named database, or a fee schedule. Then ask the number.
• Ask for the percentile in those words when verifying an out-of-network plan, and record it on the plan in your practice management system, dated. It is a plan attribute and it persists until the plan year changes.
• Re-ask each plan year on plans you see often. A programme can drop the percentile entirely, as MetLife's federal plan did between 2021 and 2026.
• Do not compute a percentile from your own remittances. Two out-of-network lines in three carry your own fee, one in eight carries no allowance, and one observation is off by a median 16.5%.
• Quote the coinsurance gap and the balance-billing gap separately, and label the second an estimate where the plan will not state its allowance. An estimate labelled uncertain survives the patient conversation; a confident wrong number does not.

Numbers last refreshed August 2026.

All articles · Kaylie