Code Description UCR Dental Plan

Preventive and Diagnostic

D0120 periodic oral evaluation - established patient 50$ -$ D0140 emergency exam 55$ -$ D0150 new patient exam 78$ -$ D0210 complete series x-rays 135$ -$ D0220 single periapical x-ray 20$ -$ D0230 each additional x-ray 18$ -$ D0274 four bitewing x-rays 60$ -$ D0460 pulp vitality tests 30$ -$ D1330 preventive dental education and home care 45$ -$ D0470 diagnostic casts 90$ 40$ D1110 regular cleaning - adult 90$ 76$ D1120 regular cleaning - child 75$ 60$ D1203 flouride treatment (one per year up to age 18) 35$ -$ D1351 sealant - per tooth 50$ 35$

Restorative (Fillings)

D2330 resin-based composite - one surface, anterior 148$ 125$ D2331 resin-based composite - two surfaces, anterior 180$ 150$ D2332 resin-based composite - three surfaces, anterior 220$ 175$ D2335 resin-based composite - four or more surfaces 270$ 230$ D2391 resin-based composite - one surface, posterior 165$ 135$ D2392 resin-based composite - two surfaces, posterior 225$ 190$ D2393 resin-based composite - three surfaces, posterior 279$ 235$ D2394 resin-based composite - four or more surfaces, posterior 329$ 280$

Crown and Bridge

D2740 ceramic crown 1,175$ 950$ D2920 re-cement crown 120$ 100$ D2950 core buildup 265$ 225$ D2954 post and core 289$ 245$ D2962 porcelain veneer 1,155$ 950$ D6057/6065 implant crown 2,092$ 1,780$ D6245 ceramic bridge pontic 950$ 810$ D6740 ceramic bridge crown 1,100$ 935$

Endodontics (Root Canal Treatment)

D3310 root canal therapy - anterior 850$ 725$ D3320 root canal therapy - bicuspid 950$ 810$ D3330 root canal therapy - molar 1,200$ 1,020$

Periodontics (Gum Treatment)

D4341 periodontal scaling and root planing - quadrant 220$ 180$ D4342 periodontal scaling and root planing - one to three teeth 165$ 140$ D4910 periodontal maintenance (up to 4 per year) 130$ 80$ D4999 laser bacterial decontamination 30$ 20$ D4999 clinical crown lengthening - laser 525$ 450$ D4249 clinical crown lengthening - flap 752$ 640$

Jason Streeter DDS | 719-590-7277 | 1685 Briargate Blvd, Suite A Colorado Springs, CO 80920

Discount Plan 2019

Code Description UCR Dental Plan

Prosthodontics - Removable

D5110 complete upper denture 1,493$ 1,250$ D5120 complete lower denture 1,493$ 1,250$ D5810 interim upper denture 885$ 750$ D5811 interim lower denture 885$ 750$ D5213 upper partial denture - cast metal framework 1,650$ 1,350$ D5214 lower partial denture - cast metal framework 1,650$ 1,350$ D5225 upper partial denture - flexible base 1,350$ 1,150$ D5226 lower partial denture - flexible base 1,350$ 1,150$

Repairs/Relines

D5410-22 denture adjustment 66$ 25$ D5510 repair broken complete denture base 210$ 160$ D5520 replace missing or broken denture tooth 130$ 110$ D5620-30 repair cast framework/clasp 230$ 190$ D5650 add tooth to existing partial denture 170$ 145$

Oral Surgery

D7140 simple extraction 168$ 140$ D7210 surgical extraction 271$ 230$ D7286 biopsy of soft tissue 329$ 280$ D7510 Incise and drain abcess 225$ 150$

Other Services

D9110 emergency palliative treatment 129$ 100$ D9210 local anesthetic -$ -$ D9230 nitrous oxide (30 mins) 55$ 40$ D9951 occlusal adjustment - limited 131$ 85$ D9975 take home bleaching - per arch 150$ 125$ D9972 in-office bleaching - per arch 220$ 180$

Jason Streeter DDS | 719-590-7277 | 1685 Briargate Blvd, Suite A Colorado Springs, CO 80920

Adult (12+): $250Additional Adult: $225 Child (under 12): $200

• the plan is active for one year from date of purchase of the primary member• includes up to two dental exams, x-rays, and flouride treatments per year• 15% off all dental treatment not specifically listed• discount plan cannot be combined with any other insurance plan or discount program• multi-member plans are limited to 2 parents and children through age 20• membership discounts and benefits are not valid at any other dental office