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 | $116 | 0% | $116 | Medium |
| Child Dental Cleaning | $92 | 0% | $92 | Medium |
| Fluoride - Topical Application | $49 | 0% | $49 | Medium |
| Sealant placed on the tooth surface to prevent decay | $65 | 0% | $65 | Medium |
| Topical fluoride varnish application | $49 | 0% | $49 | 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 | $57 | 0% | $57 | Medium |
| Problem focused evaluation limited to a specific oral health problem or complaint | $95 | 0% | $95 | Medium |
| X-Ray Dental - Complete intraoral series | $167 | 0% | $167 | Medium |
| X-Ray Dental - Four images - bitewings | $83 | 0% | $83 | Medium |
| X-Ray Dental - Intraoral - periapical radiographic image | $40 | 0% | $40 | Medium |
| X-Ray Dental - Two images - bitewings | $61 | 0% | $61 | 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 | $153 | 0% | $153 | 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 | $211 | 0% | $211 | Medium |
| Silver (Amalgam) Dental Filling - Two surfaces, primary or permanent | $284 | 0% | $284 | Medium |
| Silver (Amalgam) Dental Filling - Three surfaces, primary or permanent | $394 | 0% | $394 | Medium |
| White (Resin) Dental Filling - One surface, posterior | $211 | 0% | $211 | Medium |
| White (Resin) Dental Filling - Two surfaces, posterior | $284 | 0% | $284 | Medium |
| White (Resin) Dental Filling - One surface, anterior | $214 | 0% | $214 | Medium |
| White (Resin) Dental Filling - Three surfaces, posterior | $394 | 0% | $394 | Medium |
| White (Resin) Dental Filling - Two surfaces, anterior | $246 | 0% | $246 | 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) | $214 | 0% | $214 | Medium |