| Code | Description | Total Paid |
|---|---|---|
| D1110 | Prophylaxis - adult | $134K |
| D1120 | Prophylaxis - child | $119K |
| D4355 | $82K | |
| D9410 | $71K | |
| D1208 | Topical application of fluoride, excluding varnish | $54K |
| D0120 | Periodic oral evaluation - established patient | $50K |
| D1206 | Topical application of fluoride varnish | $44K |
| D1351 | Sealant - per tooth | $26K |
| D2392 | Resin-based composite - two surfaces, posterior, primary or permanent | $21K |
| D4341 | $21K |
| # | Provider | Location | Claims | Total Paid |
|---|---|---|---|---|
| 1 | DELIVERING SMILES INC. | FRESNO, CA | 8,266 | $378K |
| 2 | OGANDO, DELIS | JACKSON, MI | 12,678 | $326K |
| 3 | ASHBURNFARM DENTAL ARTS | ASHBURN, VA | 82 | $1K |
| 4 | COLETTE FONTAINE, RDHAP INC. | SAN MATEO, CA | 12 | $630.00 |
| 5 | MONI DENTISTRY PLLC | DALLAS, TX | 24 | $288.84 |