Springfield Medical Care System
25 Ridgewood Road Springfield, VT 05156
Dental Procedures
Preventive Care
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Adult Dental Cleaning | $93 | 0% | $93 | Medium |
| Child Dental Cleaning | $74 | 0% | $74 | Medium |
| Fluoride - Topical Application | $37 | 0% | $37 | Medium |
| Sealant placed on the tooth surface to prevent decay | $53 | 0% | $53 | Medium |
Diagnostic Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Comprehensive Dental Exam | $79 | 0% | $79 | Medium |
| Periodic dental exam - established patient | $42 | 0% | $42 | Medium |
| Problem focused evaluation limited to a specific oral health problem or complaint | $74 | 0% | $74 | Medium |
| X-Ray Dental - Four images - bitewings | $63 | 0% | $63 | Medium |
| X-Ray Dental - Intraoral - periapical radiographic image | $26 | 0% | $26 | Medium |
| X-Ray Dental - Two images - bitewings | $42 | 0% | $42 | Medium |
| X-Ray Dental - Additional image of tooth from crown to root, from inside mouth | $21 | 0% | $21 | Medium |
| X-Ray Dental - Whole mouth, from outside mouth | $110 | 0% | $110 | 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 | $179 | 0% | $179 | Medium |
| Silver (Amalgam) Dental Filling - Two surfaces, primary or permanent | $215 | 0% | $215 | Medium |
| Silver (Amalgam) Dental Filling - Three surfaces, primary or permanent | $268 | 0% | $268 | Medium |
| White (Resin) Dental Filling - One surface, posterior | $179 | 0% | $179 | Medium |
| White (Resin) Dental Filling - Two surfaces, posterior | $215 | 0% | $215 | Medium |
| White (Resin) Dental Filling - Three surfaces, posterior | $268 | 0% | $268 | Medium |
| White (Resin) Dental Filling - Two surfaces, anterior | $189 | 0% | $189 | Medium |
Orthodontic Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Orthodontic Treatment Visit (Periodic - as part of a contract) | $115 | 0% | $115 | Medium |
Other Dental Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Tooth Extraction (Elevation and/or forceps removal) | $189 | 0% | $189 | Medium |