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
Dental Cleaning - Adult$1100%$110
Dental Cleaning - Child$840%$84
Dental Exam - Comprehensive$1000%$100
Dental Exam - Periodic, Established Patient$580%$58
Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent$2100%$210
Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent$3680%$368
Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent$2680%$268
Dental Filling - White (Resin): One Surface, Anterior$1860%$186
Dental Filling - White (Resin): One Surface, Posterior$2100%$210
Dental Filling - White (Resin): Three Surfaces, Posterior$3680%$368
Dental Filling - White (Resin): Two Surfaces, Anterior$2210%$221
Dental Filling - White (Resin): Two Surfaces, Posterior$2680%$268
Flouride - Topical Varnish Application$470%$47
Fluoride - Topical Application$420%$42
Maintenance Therapy - Periodontal$1520%$152
Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant$2780%$278
Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint$950%$95
Sealant - Placed on Tooth Surface to Prevent Decay$580%$58
Tooth Extraction - Elevation and/or Forceps Removal$2100%$210
X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth$270%$27
X-Ray - Complete Intraoral Series$1580%$158
X-Ray - Four Images, Bitewings$740%$74
X-Ray - Intraoral, Periapical Radiographic Image$370%$37
X-Ray - Two Images, Bitewings$530%$53
X-Ray - Whole Mouth from Outside Mouth$1370%$137