| ADA Service Code————————————————– | Usual Fee—— | Member Fee—– | Discount % |
| D1110 Cleaning, (Prophylaxis) Adult | $81.00 | $47.00 | 42 % |
| D1120 Cleaning, (Prophylaxis) Child | $68.00 | $34.00 | 50 % |
| D1203 Fluoride Child – No cleaning | $33.00 | $5.00 | 85 % |
| D1204 Fluoride Adult – No cleaning | $34.00 | $5.00 | 85 % |
| D1351 Sealant-per tooth | $54.00 | $20.00 | 63 % |