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DENTAL DIRECTORY SERVICES Fee Schedule A

SPECIALIST SERVICESas performed by Board Eligible or Board Certified DENTAL specialistsCODE DDSAT ypicalCost*You SAVEORAL SURGERYD7111 Extraction, coronal remnants deciduous tooth$99 $170 $67 D7140 Extraction erupted tooth or exposed root (elevation and/or forceps removal)$103 $201 $98 D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and/or section of tooth - each tooth$134 $297 $163 D7220 Removal of impacted tooth-soft tissue$173 $339 $166 D7230 Removal of impacted tooth-partially bony$212 $424 $212 D7240 Removal of impacted tooth-completely bony$257 $479 $222 D7241 Removal of impacted tooth - completely bony with unusual surgical complications$314 $557 $243 D7250 Surgical removal of residual tooth roots (cutting procedure)

ADJUNCTIVE SERVICES UNCLASSIFIED TREATMENT USUAL FEE* YOUR COST YOU SAVE D9110 Palliative (emergency) treatment of dental pain - minor procedure $148 $36 $112 D9440 Office visit - after regularly scheduled hours $191 $78 $113 D9940 Occlusal guard, by report $624 $312 $312 ADA CODE ORAL SURGERY USUAL FEE* YOUR COST YOU SAVE

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