Ernani S Domingo, DMD
33 Bay Street Manchester, NH 03104
Dental Procedures
Preventive Care
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Adult Dental Cleaning | $123 | 0% | $123 | Medium |
| Child Dental Cleaning | $99 | 0% | $99 | Medium |
| Fluoride - Topical Application | $53 | 0% | $53 | Medium |
| Plaque and tartar removal from around teeth and gums-per quadrant | $296 | 0% | $296 | Medium |
| Sealant placed on the tooth surface to prevent decay | $61 | 0% | $61 | Medium |
Diagnostic Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Comprehensive Dental Exam | $109 | 0% | $109 | Medium |
| Periodic dental exam - established patient | $57 | 0% | $57 | Medium |
| X-Ray Dental - Complete intraoral series | $165 | 0% | $165 | Medium |
| X-Ray Dental - Four images - bitewings | $78 | 0% | $78 | Medium |
| X-Ray Dental - Intraoral - periapical radiographic image | $39 | 0% | $39 | Medium |
| X-Ray Dental - Two images - bitewings | $63 | 0% | $63 | Medium |
| X-Ray Dental - Additional image of tooth from crown to root, from inside mouth | $37 | 0% | $37 | Medium |
| X-Ray Dental - Whole mouth, from outside mouth | $146 | 0% | $146 | 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 | $226 | 0% | $226 | Medium |
| Silver (Amalgam) Dental Filling - Two surfaces, primary or permanent | $287 | 0% | $287 | Medium |
| Silver (Amalgam) Dental Filling - Three surfaces, primary or permanent | $412 | 0% | $412 | Medium |
| White (Resin) Dental Filling - One surface, posterior | $226 | 0% | $226 | Medium |
| White (Resin) Dental Filling - Two surfaces, posterior | $287 | 0% | $287 | Medium |
| White (Resin) Dental Filling - One surface, anterior | $215 | 0% | $215 | Medium |
| White (Resin) Dental Filling - Three surfaces, posterior | $383 | 0% | $383 | Medium |
| White (Resin) Dental Filling - Two surfaces, anterior | $247 | 0% | $247 | Medium |
Other Dental Services
| Procedure | Estimate of Total Cost | Uninsured Discount | What you Will Pay | Typical Patient Complexity |
|---|---|---|---|---|
| Maintenance Therapy - Periodontal | $156 | 0% | $156 | Medium |
| Tooth Extraction (Elevation and/or forceps removal) | $203 | 0% | $203 | Medium |