Jon W. Samaha, DMD Mmsc
13 Wall Street Concord, NH 03301
Dental Procedures
Preventive Care
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Adult Dental Cleaning | $125 | 0% | $125 | Medium |
| Child Dental Cleaning | $101 | 0% | $101 | Medium |
| Plaque and tartar removal from around teeth and gums-per quadrant | $330 | 0% | $330 | Medium |
| Sealant placed on the tooth surface to prevent decay | $71 | 0% | $71 | 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 | $167 | 0% | $167 | Medium |
| Periodic dental exam - established patient | $64 | 0% | $64 | Medium |
| Problem focused evaluation limited to a specific oral health problem or complaint | $131 | 0% | $131 | Medium |
| X-Ray Dental - Complete intraoral series | $174 | 0% | $174 | Medium |
| X-Ray Dental - Four images - bitewings | $86 | 0% | $86 | Medium |
| X-Ray Dental - Intraoral - periapical radiographic image | $40 | 0% | $40 | Medium |
| X-Ray Dental - Two images - bitewings | $64 | 0% | $64 | Medium |
| X-Ray Dental - Additional image of tooth from crown to root, from inside mouth | $38 | 0% | $38 | Medium |
| X-Ray Dental - Whole mouth, from outside mouth | $156 | 0% | $156 | 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 | $324 | 0% | $324 | Medium |
| Silver (Amalgam) Dental Filling - Three surfaces, primary or permanent | $463 | 0% | $463 | Medium |
| White (Resin) Dental Filling - One surface, anterior | $229 | 0% | $229 | Medium |
| White (Resin) Dental Filling - Three surfaces, posterior | $463 | 0% | $463 | Medium |
| White (Resin) Dental Filling - Two surfaces, anterior | $259 | 0% | $259 | Medium |
Other Dental Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Maintenance Therapy - Periodontal | $181 | 0% | $181 | Medium |
| Tooth Extraction (Elevation and/or forceps removal) | $218 | 0% | $218 | Medium |