Thomas A Johnston & Associates
206 Heater Road Lebanon, NH 03766
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 | $85 | 0% | $85 | Medium |
| Plaque and tartar removal from around teeth and gums-per quadrant | $313 | 0% | $313 | Medium |
| Topical fluoride varnish application | $56 | 0% | $56 | Medium |
Diagnostic Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Comprehensive Dental Exam | $143 | 0% | $143 | Medium |
| Periodic dental exam - established patient | $59 | 0% | $59 | Medium |
| Problem focused evaluation limited to a specific oral health problem or complaint | $104 | 0% | $104 | Medium |
| X-Ray Dental - Complete intraoral series | $231 | 0% | $231 | Medium |
| X-Ray Dental - Four images - bitewings | $86 | 0% | $86 | 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 | $23 | 0% | $23 | Medium |
| X-Ray Dental - Whole mouth, from outside mouth | $145 | 0% | $145 | 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 | $196 | 0% | $196 | Medium |
| Silver (Amalgam) Dental Filling - Two surfaces, primary or permanent | $247 | 0% | $247 | Medium |
| Silver (Amalgam) Dental Filling - Three surfaces, primary or permanent | $309 | 0% | $309 | Medium |
| White (Resin) Dental Filling - One surface, posterior | $244 | 0% | $244 | Medium |
| White (Resin) Dental Filling - Two surfaces, posterior | $298 | 0% | $298 | Medium |
| White (Resin) Dental Filling - One surface, anterior | $231 | 0% | $231 | Medium |
| White (Resin) Dental Filling - Two surfaces, anterior | $277 | 0% | $277 | Medium |
Other Dental Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Maintenance Therapy - Periodontal | $163 | 0% | $163 | Medium |
| Tooth Extraction (Elevation and/or forceps removal) | $234 | 0% | $234 | Medium |