Estimate maximum usage for planned services
Example data
Use this sample to understand typical entries.
| Description | Category | Billed | Allowed | Deductible Applies | Counts Toward Maximum |
|---|---|---|---|---|---|
| Routine Cleaning | Preventive | $120.00 | $90.00 | No | Yes |
| Composite Filling | Basic | $240.00 | $180.00 | Yes | Yes |
| Porcelain Crown | Major | $1,200.00 | $850.00 | Yes | Yes |
Formula used
This calculator estimates the plan’s payment per procedure, then applies the annual maximum cap when applicable.
- Allowed amount: use Allowed if provided; otherwise use Billed.
- Deductible applied: min(deductible remaining, allowed amount) when deductible applies.
- After deductible: allowed − deductible applied.
- Preliminary plan payment: (after deductible) × (coverage % ÷ 100).
- Coinsurance member share: (after deductible) − preliminary plan payment.
- Annual maximum cap: plan payment is limited to remaining maximum for items that count.
- Member total per procedure: deductible applied + coinsurance + any amount above the maximum.
How to use this calculator
- Enter your plan’s annual maximum, carryover, and benefit used to date.
- Enter your deductible and how much you have already met this year.
- Add each planned procedure, select its category, and confirm whether deductible applies.
- Check “Counts toward maximum” for services that use the annual cap.
- Click Calculate to see plan payment, member cost, and remaining maximum.
- Use the export buttons to save results as CSV or PDF.
FAQs
1) What is a dental annual maximum?
It is the yearly limit your plan will pay for covered dental services. Once reached, you generally pay remaining eligible costs yourself until the plan year resets.
2) Does every service count toward the maximum?
Not always. Some plans exclude certain items, such as discounts, office visits, or specific preventive services. Use your benefit summary to decide whether to check “Counts toward maximum.”
3) What is the difference between billed and allowed?
Billed is the provider’s charge. Allowed is the negotiated amount used for benefit calculations. If you know the allowed amount, enter it to improve the estimate.
4) How does the deductible affect the estimate?
If a procedure is subject to the deductible, you pay some or all of the allowed amount first. After the deductible is met, coinsurance applies based on the coverage percentage.
5) What if the plan payment exceeds the remaining maximum?
The calculator caps the plan payment at the remaining maximum for procedures that count. The unpaid portion is added to the member’s cost as maximum overage.
6) Can I model services that are not covered?
Yes. Choose “Not covered” or set a custom coverage of 0%. The estimate will place the full after-deductible amount on the member side.
7) Do orthodontic services follow the same maximum?
Some plans use a separate lifetime orthodontic maximum. If your plan does, you can uncheck “Counts toward maximum” for ortho rows and model limits separately.
8) Is this an official benefits determination?
No. It is an estimate for planning. Actual payments can differ due to claim coding, network rules, frequency limits, exclusions, and plan-specific definitions.