| ADA Service Code—————————————————- | Usual Fee—– | Member Fee— | Discount % |
| D2140 Amalgam, 1 surface | $139.00 | $40.00 | 71 % |
| D2150 Amalgam, 2 surface | $190.00 | $50.00 | 74 % |
| D2160 Amalgam, 3 surface | $248.00 | $60.00 | 76 % |
| D2161 Amalgam, 4 surface | $265.00 | $70.00 | 74 % |
| D2330 Filling, (white, composite) | $155.00 | $65.00 | 58 % |
| D2331 Anterior Composite, 2 surface | $175.00 | $79.00 | 55 % |
| D2332 Anterior Composite, 3 surface | $215.00 | $90.00 | 58 % |
| D2335 Anterior Composite, 4 surface | $269.00 | $111.00 | 59 % |
| D2391 Posterior Composite,(white filling)1 surface | $153.00 | $75.00 | 51 % |
| D2392 Posterior Composite, 2 surface | $211.00 | $93.00 | 56 % |
| D2393 Posterior Composite, 3 surface | $252.00 | $103.00 | 59 % |
| D2394 Posterior Composite, 4 + surfaces | $303.00 | $113.00 | 63 % |