Calvin Dental Associates
25 Buttrick Road Londonderry, NH 03053
Dental Procedures
Preventive Care
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Adult Dental Cleaning | $131 | 0% | $131 | Medium |
| Child Dental Cleaning | $104 | 0% | $104 | Medium |
| Fluoride - Topical Application | $47 | 0% | $47 | Medium |
| Plaque and tartar removal from around teeth and gums-per quadrant | $326 | 0% | $326 | Medium |
| Sealant placed on the tooth surface to prevent decay | $63 | 0% | $63 | Medium |
Diagnostic Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Comprehensive Dental Exam | $158 | 0% | $158 | Medium |
| Periodic dental exam - established patient | $70 | 0% | $70 | Medium |
| Problem focused evaluation limited to a specific oral health problem or complaint | $126 | 0% | $126 | Medium |
| X-Ray Dental - Complete intraoral series | $179 | 0% | $179 | Medium |
| X-Ray Dental - Four images - bitewings | $89 | 0% | $89 | Medium |
| X-Ray Dental - Intraoral - periapical radiographic image | $42 | 0% | $42 | Medium |
| X-Ray Dental - Two images - bitewings | $60 | 0% | $60 | Medium |
| X-Ray Dental - Additional image of tooth from crown to root, from inside mouth | $32 | 0% | $32 | Medium |
| X-Ray Dental - Whole mouth, from outside mouth | $179 | 0% | $179 | 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 | $231 | 0% | $231 | Medium |
| Silver (Amalgam) Dental Filling - Two surfaces, primary or permanent | $305 | 0% | $305 | Medium |
| Silver (Amalgam) Dental Filling - Three surfaces, primary or permanent | $368 | 0% | $368 | Medium |
| White (Resin) Dental Filling - One surface, posterior | $231 | 0% | $231 | Medium |
| White (Resin) Dental Filling - Two surfaces, posterior | $305 | 0% | $305 | Medium |
| White (Resin) Dental Filling - One surface, anterior | $226 | 0% | $226 | Medium |
| White (Resin) Dental Filling - Three surfaces, posterior | $368 | 0% | $368 | Medium |
| White (Resin) Dental Filling - Two surfaces, anterior | $268 | 0% | $268 | Medium |
Other Dental Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Maintenance Therapy - Periodontal | $189 | 0% | $189 | Medium |
| Tooth Extraction (Elevation and/or forceps removal) | $236 | 0% | $236 | Medium |