Upper Valley Pediatric Dentistry
30 Airport Road, Suite 1 West Lebanon, NH 03784
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 | $98 | 0% | $98 | Medium |
| Sealant placed on the tooth surface to prevent decay | $68 | 0% | $68 | 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 | $106 | 0% | $106 | Medium |
| Periodic dental exam - established patient | $58 | 0% | $58 | Medium |
| Problem focused evaluation limited to a specific oral health problem or complaint | $103 | 0% | $103 | Medium |
| X-Ray Dental - Complete intraoral series | $232 | 0% | $232 | Medium |
| X-Ray Dental - Four images - bitewings | $83 | 0% | $83 | Medium |
| X-Ray Dental - Intraoral - periapical radiographic image | $39 | 0% | $39 | Medium |
| X-Ray Dental - Two images - bitewings | $59 | 0% | $59 | Medium |
| X-Ray Dental - Additional image of tooth from crown to root, from inside mouth | $32 | 0% | $32 | Medium |
| X-Ray Dental - Whole mouth, from outside mouth | $151 | 0% | $151 | 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 | $221 | 0% | $221 | Medium |
| Silver (Amalgam) Dental Filling - Two surfaces, primary or permanent | $308 | 0% | $308 | Medium |
| Silver (Amalgam) Dental Filling - Three surfaces, primary or permanent | $273 | 0% | $273 | Medium |
| White (Resin) Dental Filling - One surface, posterior | $221 | 0% | $221 | Medium |
| White (Resin) Dental Filling - Two surfaces, posterior | $308 | 0% | $308 | Medium |
| White (Resin) Dental Filling - One surface, anterior | $200 | 0% | $200 | Medium |
| White (Resin) Dental Filling - Three surfaces, posterior | $401 | 0% | $401 | 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 |
|---|---|---|---|---|
| Tooth Extraction (Elevation and/or forceps removal) | $221 | 0% | $221 | Medium |