Gorham Family Dentistry
2 Broadway Avenue Gorham, NH 03581
Dental Procedures
Preventive Care
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Adult Dental Cleaning | $104 | 0% | $104 | 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 | $275 | 0% | $275 | Medium |
| Sealant placed on the tooth surface to prevent decay | $63 | 0% | $63 | Medium |
| Topical fluoride varnish application | $42 | 0% | $42 | Medium |
Diagnostic Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Comprehensive Dental Exam | $90 | 0% | $90 | Medium |
| Periodic dental exam - established patient | $64 | 0% | $64 | Medium |
| Problem focused evaluation limited to a specific oral health problem or complaint | $88 | 0% | $88 | Medium |
| X-Ray Dental - Complete intraoral series | $145 | 0% | $145 | Medium |
| X-Ray Dental - Four images - bitewings | $80 | 0% | $80 | Medium |
| X-Ray Dental - Intraoral - periapical radiographic image | $35 | 0% | $35 | Medium |
| X-Ray Dental - Two images - bitewings | $65 | 0% | $65 | 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 | $145 | 0% | $145 | 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 | $188 | 0% | $188 | Medium |
| Silver (Amalgam) Dental Filling - Two surfaces, primary or permanent | $261 | 0% | $261 | Medium |
| Silver (Amalgam) Dental Filling - Three surfaces, primary or permanent | $340 | 0% | $340 | Medium |
| White (Resin) Dental Filling - One surface, posterior | $188 | 0% | $188 | Medium |
| White (Resin) Dental Filling - Two surfaces, posterior | $261 | 0% | $261 | Medium |
| White (Resin) Dental Filling - One surface, anterior | $164 | 0% | $164 | Medium |
| White (Resin) Dental Filling - Three surfaces, posterior | $340 | 0% | $340 | Medium |
| White (Resin) Dental Filling - Two surfaces, anterior | $201 | 0% | $201 | 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) | $158 | 0% | $158 | Medium |