Tri-County Community Action
2957 Main Street Bethlehem, NH 03574
Dental Procedures
Preventive Care
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Adult Dental Cleaning | $99 | 0% | $99 | Medium |
| Child Dental Cleaning | $120 | 0% | $120 | Medium |
| Fluoride - Topical Application | $48 | 0% | $48 | Medium |
| Plaque and tartar removal from around teeth and gums-per quadrant | $275 | 0% | $275 | Medium |
| Sealant placed on the tooth surface to prevent decay | $57 | 0% | $57 | Medium |
Diagnostic Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Comprehensive Dental Exam | $96 | 0% | $96 | Medium |
| Periodic dental exam - established patient | $54 | 0% | $54 | Medium |
| Problem focused evaluation limited to a specific oral health problem or complaint | $79 | 0% | $79 | Medium |
| X-Ray Dental - Complete intraoral series | $146 | 0% | $146 | Medium |
| X-Ray Dental - Four images - bitewings | $71 | 0% | $71 | Medium |
| X-Ray Dental - Intraoral - periapical radiographic image | $29 | 0% | $29 | Medium |
| X-Ray Dental - Two images - bitewings | $76 | 0% | $76 | Medium |
| X-Ray Dental - Additional image of tooth from crown to root, from inside mouth | $25 | 0% | $25 | 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 | $184 | 0% | $184 | Medium |
| Silver (Amalgam) Dental Filling - Two surfaces, primary or permanent | $242 | 0% | $242 | Medium |
| Silver (Amalgam) Dental Filling - Three surfaces, primary or permanent | $311 | 0% | $311 | Medium |
| White (Resin) Dental Filling - One surface, posterior | $193 | 0% | $193 | Medium |
| White (Resin) Dental Filling - Two surfaces, posterior | $254 | 0% | $254 | Medium |
| White (Resin) Dental Filling - One surface, anterior | $167 | 0% | $167 | Medium |
| White (Resin) Dental Filling - Three surfaces, posterior | $296 | 0% | $296 | Medium |
| White (Resin) Dental Filling - Two surfaces, anterior | $208 | 0% | $208 | Medium |
Other Dental Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Maintenance Therapy - Periodontal | $146 | 0% | $146 | Medium |
| Tooth Extraction (Elevation and/or forceps removal) | $184 | 0% | $184 | Medium |