| ADA Service Code————————————————- | Usual Fee—– | Member Fee– | Discount % |
| D4210 Gingivectomy – 4+ teeth per quadrant | $544.00 | $295.00 | 46 % |
| D4211 Gingivectomy 1 to 3 teeth per quadrant | $262.00 | $85.00 | 68 % |
| D4240 Gingival flap – 4+ contiguous teeth/quad. | $661.00 | $295.00 | 55 % |
| D4241 Gingival flap – 1 to 3 teeth per quadrant | $345.00 | $195.00 | 43 % |
| D4341 Scaling/root planing, 4+ teeth per quad | $222.00 | $110.00 | 50 % |
| D4342 Scaling/root planning, 1 to 3 teeth per quad | $140.00 | $63.00 | 55 % |
| D4355 Full mouth debridement | $185.00 | $75.00 | 59 % |
| D4910 Periodontal maintenance, per visit | $146.00 | $63.00 | 57 % |