Pacific Dental Hygiene Clinic Services

Dental hygiene students perform all services under the supervision of licensed dental health professionals. Our services are limited to preventive and limited basic restorative services. We do not offer crowns, extractions, etc., nor do we treat dental emergencies.

Our services are not intended to replace comprehensive dental care provided by your dentist.

Treatment Plans

A treatment plan will be developed to meet your oral health needs and may include:

  • Health screening with blood pressure check and oral cancer screening
  • Dental examination
  • Non-surgical periodontal care
  • Oral prophylaxis (teeth cleaning)
  • Oral health instruction with home care kit
  • Dental radiographs (x-rays)
  • Fluoride treatment
  • Denture/removable appliance cleaning
  • Sealants
  • Intraoral photographs


Fees for care are based upon services needed and necessary supplies. There is no fee for the screening visit. Payment is expected on the day services are provided. Payment options can be discussed prior to treatment with our financial coordinator. Our clinic accepts most insurance programs and will bill your carrier.

ADA Codes and Fees | The clinic will use the accepted ADA codes for billing purposes. The fees are set by the clinic and updated yearly. This fee schedule has been accepted beginning January, 2024.

Dental Health Clinic Fee Schedule | Honorarios en Español 

Diagnostic/Diagnostico Fee/Honararios
Dental Exam - Examen Dental No charge/Sin cobro
D0272 2BWX $15
D0274 4 BWX $30
D0210 FMX or D0330 PANO $50
D0220 Single PA $8
Dental Hygiene Cleaning/Limpieza Higiene Dental  
D1110 Adult - Routine cleaning/Adulto-Limpieza de rutina $50
D1120 Child - Routine cleaning/Menor-Limpieza de rutina $30
D1206 Fluoride varnish/Fluoruro varnish $5
D1354 Silver Diamine Fluoride/Fluoruro Diamino de Plata $5
D1351 Sealant per tooth/Sello por diente $15
Periodontal Treatment/Tratamiento Periodontal  
D4910 Periodontal maintenance/Mantenimiento periodontal $80
Deep cleaning full mouth/Limpieza profunda $200-$320
D4342 SRP 1-3 teeth $50 per quad/por cuadrante
D4341 SRP 4+ teeth $80 per quad/por cuadrante
D4346 Scaling with Mod/Severe Inflammation $80
Restorative Treatment (Fillings)/Tratamiento de Restauración (Rellenos)  
1 Surface filling/1 Superficie - Relleno $70
2 Surface filling/2 Superficie - Relleno $80
3 Surface filling/3 Superficie - Relleno $90
4 Surface filling/4 Superficie - Relleno $100
Miscelanneous/Misceláneo o Adicionales  
Nitrous oxide/óxido nitroso (Gas Hilarante) $30 per visit/por cita
Sports guard/Protector bucal $30
Bleach trays/Bandejas para blanquear (includes gel/Incluye gel) $85
Bleach refill/Remplazo de gel para blanquear $20 (2) 
Opalescence strips/Tiras de blanquear $20 (4)
Clinpro 5000 $20
Peridex rinse/Enjuague Peridex $15
Oral-B Vitality (electric toothbrush/cepillo dental eléctrico) $20
Oral B IO (electric tooth brush system/cepillo dental electronico) $70
Toothbrush heads/Cabeza de cepillo eléctrico $10-$25
Desensitizing medicament/Medicamento desensibilizante $15 per visit/por cita

Fees effective as of January 1, 2023