MID-STATE Health Center

859 Lake Street Bristol, NH 03222
Dental Procedures
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ProcedureEstimate of Total Cost Uninsured Discount What You Will Pay Typical Patient Complexity
Dental Cleaning - Adult$1050%$105 Medium
Dental Cleaning - Child$840%$84 Medium
Dental Exam - Comprehensive$950%$95 Medium
Dental Exam - Periodic, Established Patient$530%$53 Medium
Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent$2100%$210 Medium
Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent$3410%$341 Medium
Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent$2630%$263 Medium
Dental Filling - White (Resin): One Surface, Anterior$1840%$184 Medium
Dental Filling - White (Resin): One Surface, Posterior$2100%$210 Medium
Dental Filling - White (Resin): Three Surfaces, Posterior$3410%$341 Medium
Dental Filling - White (Resin): Two Surfaces, Anterior$2210%$221 Medium
Dental Filling - White (Resin): Two Surfaces, Posterior$2630%$263 Medium
Flouride - Topical Varnish Application$420%$42 Medium
Maintenance Therapy - Periodontal$1520%$152 Medium
Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant$2780%$278 Medium
Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint$890%$89 Medium
Sealant - Placed on Tooth Surface to Prevent Decay$580%$58 Medium
Tooth Extraction - Elevation and/or Forceps Removal$2050%$205 Medium
X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth$270%$27 Medium
X-Ray - Complete Intraoral Series$1580%$158 Medium
X-Ray - Four Images, Bitewings$740%$74 Medium
X-Ray - Intraoral, Periapical Radiographic Image$370%$37 Medium
X-Ray - Two Images, Bitewings$530%$53 Medium
X-Ray - Whole Mouth from Outside Mouth$1310%$131 Medium