Pediatric Dentistry of Salem
389 Main Street Salem, NH 03079
Dental Procedures
Preventive Care
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Adult Dental Cleaning | $116 | 0% | $116 | Medium |
| Child Dental Cleaning | $91 | 0% | $91 | Medium |
| Fluoride - Topical Application | $42 | 0% | $42 | Medium |
| Sealant placed on the tooth surface to prevent decay | $62 | 0% | $62 | 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 | $98 | 0% | $98 | Medium |
| Periodic dental exam - established patient | $59 | 0% | $59 | Medium |
| Problem focused evaluation limited to a specific oral health problem or complaint | $96 | 0% | $96 | Medium |
| X-Ray Dental - Complete intraoral series | $198 | 0% | $198 | Medium |
| X-Ray Dental - Four images - bitewings | $77 | 0% | $77 | Medium |
| X-Ray Dental - Intraoral - periapical radiographic image | $38 | 0% | $38 | Medium |
| X-Ray Dental - Two images - bitewings | $55 | 0% | $55 | Medium |
| X-Ray Dental - Additional image of tooth from crown to root, from inside mouth | $33 | 0% | $33 | Medium |
| X-Ray Dental - Whole mouth, from outside mouth | $144 | 0% | $144 | 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 | $368 | 0% | $368 | Medium |
| Silver (Amalgam) Dental Filling - Two surfaces, primary or permanent | $228 | 0% | $228 | Medium |
| Silver (Amalgam) Dental Filling - Three surfaces, primary or permanent | $296 | 0% | $296 | Medium |
| White (Resin) Dental Filling - One surface, posterior | $184 | 0% | $184 | Medium |
| White (Resin) Dental Filling - Two surfaces, posterior | $228 | 0% | $228 | Medium |
| White (Resin) Dental Filling - One surface, anterior | $184 | 0% | $184 | Medium |
| White (Resin) Dental Filling - Three surfaces, posterior | $444 | 0% | $444 | Medium |
| White (Resin) Dental Filling - Two surfaces, anterior | $441 | 0% | $441 | Medium |
Other Dental Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Tooth Extraction (Elevation and/or forceps removal) | $205 | 0% | $205 | Medium |