John Scott Grisham, DDS
35 Union Street Littleton, NH 03561
Dental Procedures
Preventive Care
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Adult Dental Cleaning | $122 | 0% | $122 | Medium |
| Child Dental Cleaning | $97 | 0% | $97 | Medium |
| Fluoride - Topical Application | $51 | 0% | $51 | Medium |
| Sealant placed on the tooth surface to prevent decay | $65 | 0% | $65 | Medium |
| Topical fluoride varnish application | $51 | 0% | $51 | Medium |
Diagnostic Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Comprehensive Dental Exam | $145 | 0% | $145 | Medium |
| Periodic dental exam - established patient | $60 | 0% | $60 | Medium |
| Problem focused evaluation limited to a specific oral health problem or complaint | $100 | 0% | $100 | Medium |
| X-Ray Dental - Complete intraoral series | $171 | 0% | $171 | Medium |
| X-Ray Dental - Four images - bitewings | $87 | 0% | $87 | Medium |
| X-Ray Dental - Intraoral - periapical radiographic image | $42 | 0% | $42 | Medium |
| X-Ray Dental - Two images - bitewings | $63 | 0% | $63 | 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 | $161 | 0% | $161 | 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 | $222 | 0% | $222 | Medium |
| Silver (Amalgam) Dental Filling - Two surfaces, primary or permanent | $298 | 0% | $298 | Medium |
| Silver (Amalgam) Dental Filling - Three surfaces, primary or permanent | $414 | 0% | $414 | Medium |
| White (Resin) Dental Filling - One surface, posterior | $222 | 0% | $222 | Medium |
| White (Resin) Dental Filling - Two surfaces, posterior | $298 | 0% | $298 | Medium |
| White (Resin) Dental Filling - One surface, anterior | $214 | 0% | $214 | Medium |
| White (Resin) Dental Filling - Three surfaces, posterior | $414 | 0% | $414 | Medium |
| White (Resin) Dental Filling - Two surfaces, anterior | $258 | 0% | $258 | 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) | $225 | 0% | $225 | Medium |