Angela J. Santavicca, DDS
367 NH Route 121 Lebanon, NH 03766
Dental Procedures
Preventive Care
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Adult Dental Cleaning | $97 | 0% | $97 | Medium |
| Child Dental Cleaning | $83 | 0% | $83 | Medium |
| Fluoride - Topical Application | $42 | 0% | $42 | Medium |
| Plaque and tartar removal from around teeth and gums-per quadrant | $254 | 0% | $254 | Medium |
| Sealant placed on the tooth surface to prevent decay | $57 | 0% | $57 | Medium |
| Topical fluoride varnish application | $45 | 0% | $45 | Medium |
Diagnostic Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Comprehensive Dental Exam | $83 | 0% | $83 | Medium |
| Periodic dental exam - established patient | $49 | 0% | $49 | Medium |
| Problem focused evaluation limited to a specific oral health problem or complaint | $88 | 0% | $88 | Medium |
| X-Ray Dental - Complete intraoral series | $140 | 0% | $140 | Medium |
| X-Ray Dental - Four images - bitewings | $65 | 0% | $65 | Medium |
| X-Ray Dental - Intraoral - periapical radiographic image | $30 | 0% | $30 | Medium |
| X-Ray Dental - Two images - bitewings | $50 | 0% | $50 | Medium |
| X-Ray Dental - Additional image of tooth from crown to root, from inside mouth | $26 | 0% | $26 | Medium |
| X-Ray Dental - Whole mouth, from outside mouth | $126 | 0% | $126 | 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 | $187 | 0% | $187 | Medium |
| Silver (Amalgam) Dental Filling - Two surfaces, primary or permanent | $221 | 0% | $221 | Medium |
| Silver (Amalgam) Dental Filling - Three surfaces, primary or permanent | $275 | 0% | $275 | Medium |
| White (Resin) Dental Filling - One surface, posterior | $166 | 0% | $166 | Medium |
| White (Resin) Dental Filling - Two surfaces, posterior | $221 | 0% | $221 | Medium |
| White (Resin) Dental Filling - One surface, anterior | $164 | 0% | $164 | Medium |
| White (Resin) Dental Filling - Three surfaces, posterior | $275 | 0% | $275 | Medium |
| White (Resin) Dental Filling - Two surfaces, anterior | $191 | 0% | $191 | Medium |
Other Dental Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Maintenance Therapy - Periodontal | $150 | 0% | $150 | Medium |
| Tooth Extraction (Elevation and/or forceps removal) | $183 | 0% | $183 | Medium |