Paul Walter Golas, DMD
262 Derry Road Litchfield, NH 03052
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 | $96 | 0% | $96 | Medium |
| Plaque and tartar removal from around teeth and gums-per quadrant | $330 | 0% | $330 | Medium |
| Topical fluoride varnish application | $84 | 0% | $84 | Medium |
Diagnostic Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Comprehensive Dental Exam | $97 | 0% | $97 | Medium |
| Periodic dental exam - established patient | $60 | 0% | $60 | Medium |
| Problem focused evaluation limited to a specific oral health problem or complaint | $125 | 0% | $125 | Medium |
| X-Ray Dental - Complete intraoral series | $174 | 0% | $174 | Medium |
| X-Ray Dental - Four images - bitewings | $84 | 0% | $84 | Medium |
| X-Ray Dental - Intraoral - periapical radiographic image | $37 | 0% | $37 | Medium |
| X-Ray Dental - Two images - bitewings | $62 | 0% | $62 | Medium |
| X-Ray Dental - Additional image of tooth from crown to root, from inside mouth | $28 | 0% | $28 | 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 | $214 | 0% | $214 | Medium |
| Silver (Amalgam) Dental Filling - Two surfaces, primary or permanent | $270 | 0% | $270 | Medium |
| Silver (Amalgam) Dental Filling - Three surfaces, primary or permanent | $351 | 0% | $351 | Medium |
| White (Resin) Dental Filling - One surface, posterior | $214 | 0% | $214 | Medium |
| White (Resin) Dental Filling - Two surfaces, posterior | $270 | 0% | $270 | Medium |
| White (Resin) Dental Filling - One surface, anterior | $192 | 0% | $192 | Medium |
| White (Resin) Dental Filling - Three surfaces, posterior | $369 | 0% | $369 | Medium |
| White (Resin) Dental Filling - Two surfaces, anterior | $323 | 0% | $323 | Medium |
Other Dental Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Maintenance Therapy - Periodontal | $222 | 0% | $222 | Medium |
| Tooth Extraction (Elevation and/or forceps removal) | $206 | 0% | $206 | Medium |