| ADA Code | Dental Treatment | Usual Fee | Patient Charges | Member Savings |
| 150 | Comprehensive Oral Exam | $60.00 | Free | $60.00 |
| 120 | Periodic Oral Exam | $40.00 | Free | $40.00 |
| 210 | Intraoral Radiographs Complete Series (inc. bitewings) | $100.00 | Free | $100.00 |
| 274 | Bitewing (4) | $45.00 | Free | $45.00 |
| 330 | X-Rays Panoramic Film | $85.00 | Free | $85.00 |
| 1110 | Adult Cleaning (once every 6 months) | $65.00 | Free | $65.00 |
| 1120 | Child Cleaning (once every 6 months) | $50.00 | Free | $50.00 |
| 9430 | Office Visit | $60.00 | $5.00 | $55.00 |
| 7110 | Single tooth | $110.00 | $25.00 | $85.00 |
| 2110 | Silver Filling | $80.00 | $25.00 | $55.00 |
| 1351 | Sealants per tooth (to age 14) | $40.00 | $15.00 | $25.00 |
| 2950, 2952 & 2954 | Post/Pin and Core Build-up in addition to Crown | $200.00 | $95.00 | $105.00 |
| 3310 | Anterior Root Canal | $539.00 | $175.00 | $364.00 |
| 3320 | Bicuspid Root Canal | $645.00 | $235.00 | $410.00 |
| 3330 | Molar Root Canal | $785.00 | $325.00 | $460.00 |
| 5110 | Complete Upper Denture (Standard) | $1,250.00 | $350.00 | $900.00 |