MID-STATE Health Center
859 Lake Street Bristol, NH 03222
Dental Procedures
Preventive Care
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Adult Dental Cleaning | $105 | 0% | $105 | Medium |
| Child Dental Cleaning | $84 | 0% | $84 | Medium |
| Plaque and tartar removal from around teeth and gums-per quadrant | $278 | 0% | $278 | Medium |
| Sealant placed on the tooth surface to prevent decay | $58 | 0% | $58 | 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 | $95 | 0% | $95 | Medium |
| Periodic dental exam - established patient | $53 | 0% | $53 | Medium |
| Problem focused evaluation limited to a specific oral health problem or complaint | $89 | 0% | $89 | Medium |
| X-Ray Dental - Complete intraoral series | $158 | 0% | $158 | Medium |
| X-Ray Dental - Four images - bitewings | $74 | 0% | $74 | Medium |
| X-Ray Dental - Intraoral - periapical radiographic image | $37 | 0% | $37 | Medium |
| X-Ray Dental - Two images - bitewings | $53 | 0% | $53 | Medium |
| X-Ray Dental - Additional image of tooth from crown to root, from inside mouth | $27 | 0% | $27 | Medium |
| X-Ray Dental - Whole mouth, from outside mouth | $131 | 0% | $131 | 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 | $210 | 0% | $210 | Medium |
| Silver (Amalgam) Dental Filling - Two surfaces, primary or permanent | $263 | 0% | $263 | Medium |
| Silver (Amalgam) Dental Filling - Three surfaces, primary or permanent | $328 | 0% | $328 | Medium |
| White (Resin) Dental Filling - One surface, posterior | $210 | 0% | $210 | Medium |
| White (Resin) Dental Filling - Two surfaces, posterior | $263 | 0% | $263 | Medium |
| White (Resin) Dental Filling - One surface, anterior | $184 | 0% | $184 | Medium |
| White (Resin) Dental Filling - Three surfaces, posterior | $341 | 0% | $341 | Medium |
| White (Resin) Dental Filling - Two surfaces, anterior | $221 | 0% | $221 | Medium |
Other Dental Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Maintenance Therapy - Periodontal | $152 | 0% | $152 | Medium |
| Tooth Extraction (Elevation and/or forceps removal) | $205 | 0% | $205 | Medium |