SOUTH OGDEN PEDIATRIC DENTAL P.C.
NPI: 1104834191
· WASHINGTON TERRACE, UT 84405
· Pediatric Dentist
· NPI assigned 08/04/2006
$101K
Total Medicaid Paid
Provider Details
| Authorized Official | RALLISON, M. (OWNER) |
| NPI Enumeration Date | 08/04/2006 |
Monthly Spending Trend
Yearly Breakdown
| Year | Claims | Total Paid |
|---|
| 2018 |
109 |
$2K |
| 2021 |
128 |
$3K |
| 2022 |
2,043 |
$52K |
| 2023 |
1,583 |
$34K |
| 2024 |
444 |
$10K |
Billing Codes
| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
650 |
644 |
$33K |
| D1120 |
Prophylaxis - child |
867 |
859 |
$27K |
| D0272 |
Bitewings - two radiographic images |
578 |
572 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
103 |
$9K |
| D1206 |
Topical application of fluoride varnish |
820 |
812 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
724 |
705 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
564 |
553 |
$3K |