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 | $96 | 0% | $96 | Medium |
| Fluoride - Topical Application | $50 | 0% | $50 | 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 |
| Topical fluoride varnish application | $50 | 0% | $50 | 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 |
| Problem focused evaluation limited to a specific oral health problem or complaint | $104 | 0% | $104 | Medium |
| X-Ray Dental - Complete intraoral series | $159 | 0% | $159 | 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 | $62 | 0% | $62 | Medium |
| X-Ray Dental - Additional image of tooth from crown to root, from inside mouth | $36 | 0% | $36 | Medium |
| X-Ray Dental - Whole mouth, from outside mouth | $141 | 0% | $141 | 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 | $282 | 0% | $282 | Medium |
| Silver (Amalgam) Dental Filling - Three surfaces, primary or permanent | $383 | 0% | $383 | 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 | $180 | 0% | $180 | Medium |
| White (Resin) Dental Filling - Three surfaces, posterior | $383 | 0% | $383 | Medium |
| White (Resin) Dental Filling - Two surfaces, anterior | $237 | 0% | $237 | 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) | $393 | 0% | $393 | Medium |