Perry Family Dental Care
18 Elm Street Antrim, NH 03440
Dental Procedures
Preventive Care
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Adult Dental Cleaning | $112 | 0% | $112 | Medium |
| Child Dental Cleaning | $90 | 0% | $90 | Medium |
| Fluoride - Topical Application | $46 | 0% | $46 | Medium |
| Plaque and tartar removal from around teeth and gums-per quadrant | $307 | 0% | $307 | Medium |
| Sealant placed on the tooth surface to prevent decay | $62 | 0% | $62 | Medium |
| Topical fluoride varnish application | $44 | 0% | $44 | Medium |
Diagnostic Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Comprehensive Dental Exam | $105 | 0% | $105 | Medium |
| Periodic dental exam - established patient | $60 | 0% | $60 | Medium |
| Problem focused evaluation limited to a specific oral health problem or complaint | $95 | 0% | $95 | Medium |
| X-Ray Dental - Complete intraoral series | $158 | 0% | $158 | Medium |
| X-Ray Dental - Four images - bitewings | $79 | 0% | $79 | Medium |
| X-Ray Dental - Intraoral - periapical radiographic image | $37 | 0% | $37 | Medium |
| X-Ray Dental - Two images - bitewings | $54 | 0% | $54 | Medium |
| X-Ray Dental - Additional image of tooth from crown to root, from inside mouth | $29 | 0% | $29 | Medium |
| X-Ray Dental - Whole mouth, from outside mouth | $139 | 0% | $139 | 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 | $213 | 0% | $213 | Medium |
| Silver (Amalgam) Dental Filling - Two surfaces, primary or permanent | $284 | 0% | $284 | Medium |
| Silver (Amalgam) Dental Filling - Three surfaces, primary or permanent | $368 | 0% | $368 | Medium |
| White (Resin) Dental Filling - One surface, posterior | $213 | 0% | $213 | Medium |
| White (Resin) Dental Filling - Two surfaces, posterior | $284 | 0% | $284 | Medium |
| White (Resin) Dental Filling - One surface, anterior | $193 | 0% | $193 | Medium |
| White (Resin) Dental Filling - Three surfaces, posterior | $368 | 0% | $368 | Medium |
| White (Resin) Dental Filling - Two surfaces, anterior | $242 | 0% | $242 | Medium |
Other Dental Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Maintenance Therapy - Periodontal | $158 | 0% | $158 | Medium |
| Tooth Extraction (Elevation and/or forceps removal) | $218 | 0% | $218 | Medium |