Belmont Family Dental Center
Dental Procedures
Preventive Care
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Adult Dental Cleaning | $120 | 0% | $120 | Medium |
| Child Dental Cleaning | $84 | 0% | $84 | Medium |
| Fluoride - Topical Application | $43 | 0% | $43 | Medium |
| Plaque and tartar removal from around teeth and gums-per quadrant | $303 | 0% | $303 | Medium |
| Sealant placed on the tooth surface to prevent decay | $67 | 0% | $67 | Medium |
| Topical fluoride varnish application | $70 | 0% | $70 | Medium |
Diagnostic Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Comprehensive Dental Exam | $103 | 0% | $103 | Medium |
| Periodic dental exam - established patient | $58 | 0% | $58 | Medium |
| Problem focused evaluation limited to a specific oral health problem or complaint | $87 | 0% | $87 | Medium |
| X-Ray Dental - Complete intraoral series | $222 | 0% | $222 | Medium |
| X-Ray Dental - Four images - bitewings | $82 | 0% | $82 | Medium |
| X-Ray Dental - Intraoral - periapical radiographic image | $43 | 0% | $43 | Medium |
| X-Ray Dental - Two images - bitewings | $58 | 0% | $58 | Medium |
| X-Ray Dental - Additional image of tooth from crown to root, from inside mouth | $34 | 0% | $34 | Medium |
| X-Ray Dental - Whole mouth, from outside mouth | $152 | 0% | $152 | Medium |
Dental Fillings
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Silver (Amalgam) Dental Filling - One surface, primary or permanent | $213 | 0% | $213 | Medium |
| Silver (Amalgam) Dental Filling - Two surfaces, primary or permanent | $278 | 0% | $278 | Medium |
| Silver (Amalgam) Dental Filling - Three surfaces, primary or permanent | $345 | 0% | $345 | Medium |
| White (Resin) Dental Filling - One surface, posterior | $213 | 0% | $213 | Medium |
| White (Resin) Dental Filling - Two surfaces, posterior | $278 | 0% | $278 | Medium |
| White (Resin) Dental Filling - One surface, anterior | $187 | 0% | $187 | Medium |
| White (Resin) Dental Filling - Three surfaces, posterior | $345 | 0% | $345 | Medium |
| White (Resin) Dental Filling - Two surfaces, anterior | $240 | 0% | $240 | Medium |
Other Dental Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Maintenance Therapy - Periodontal | $180 | 0% | $180 | Medium |
| Tooth Extraction (Elevation and/or forceps removal) | $227 | 0% | $227 | Medium |