Richard Michael Roy, DDS
103 Main Street. Wilton, NH 03086
Dental Procedures
Preventive Care
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Adult Dental Cleaning | $122 | 0% | $122 | Medium |
| Child Dental Cleaning | $90 | 0% | $90 | Medium |
| Fluoride - Topical Application | $65 | 0% | $65 | Medium |
| Plaque and tartar removal from around teeth and gums-per quadrant | $293 | 0% | $293 | Medium |
| Sealant placed on the tooth surface to prevent decay | $53 | 0% | $53 | Medium |
| Topical fluoride varnish application | $53 | 0% | $53 | Medium |
Diagnostic Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Comprehensive Dental Exam | $104 | 0% | $104 | Medium |
| Periodic dental exam - established patient | $53 | 0% | $53 | Medium |
| Problem focused evaluation limited to a specific oral health problem or complaint | $102 | 0% | $102 | Medium |
| X-Ray Dental - Complete intraoral series | $205 | 0% | $205 | Medium |
| X-Ray Dental - Four images - bitewings | $75 | 0% | $75 | Medium |
| X-Ray Dental - Intraoral - periapical radiographic image | $44 | 0% | $44 | 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 | $33 | 0% | $33 | Medium |
| X-Ray Dental - Whole mouth, from outside mouth | $203 | 0% | $203 | 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 | $208 | 0% | $208 | Medium |
| Silver (Amalgam) Dental Filling - Two surfaces, primary or permanent | $271 | 0% | $271 | Medium |
| Silver (Amalgam) Dental Filling - Three surfaces, primary or permanent | $297 | 0% | $297 | Medium |
| White (Resin) Dental Filling - One surface, posterior | $343 | 0% | $343 | Medium |
| White (Resin) Dental Filling - Two surfaces, posterior | $271 | 0% | $271 | Medium |
| White (Resin) Dental Filling - One surface, anterior | $204 | 0% | $204 | Medium |
| White (Resin) Dental Filling - Three surfaces, posterior | $657 | 0% | $657 | Medium |
| White (Resin) Dental Filling - Two surfaces, anterior | $259 | 0% | $259 | Medium |
Other Dental Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Maintenance Therapy - Periodontal | $171 | 0% | $171 | Medium |
| Tooth Extraction (Elevation and/or forceps removal) | $204 | 0% | $204 | Medium |