| National Provider Identifier [NPI]: | 1477555308 |
| Last Name Of The Provider | FONNER |
| First Name Of The Provider | BRENT |
| Middle Initial Of The Provider | T |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | PROVENA MERCY MEDICAL CENTER / PATHOLOGY DEPARTMENT |
| Street Address 2 Of The Provider | 1325 NORTH HIGHLAND AVENUE |
| City Of The Provider | AURORA |
| Zip Code Of The Provider | 60506 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 154 |
| Number Of Services | 12262 |
| Number Of Medicare Beneficiaries | 1992 |
| Total Submitted Charge Amount | 879417.92 |
| Total Medicare Allowed Amount | 230135.26 |
| Total Medicare Payment Amount | 174845.45 |
| Total Medicare Standardized Payment Amount | 169075.29 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 3 |
| Number Of Drug Services | 9137 |
| Number Of Medicare Beneficiaries With Drug Services | 103 |
| Total Drug Submitted ChargeAmount | 10837.28 |
| Total Drug Medicare AllowedAmount | 2155.61 |
| Total Drug Medicare PaymentAmount | 1469.27 |
| Total Drug Medicare Standardized Payment Amount | 1469.27 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 151 |
| Number Of Medical Services | 3125 |
| Number Of Medicare Beneficiaries With Medical Services | 1992 |
| Total Medical Submitted Charge Amount | 868580.64 |
| Total Medical Medicare Allowed Amount | 227979.65 |
| Total Medical Medicare Payment Amount | 173376.18 |
| Total Medical Medicare Standardized Payment Amount | 167606.02 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 272 |
| Number Of Beneficiaries Age 65 to 74 | 911 |
| Number Of Beneficiaries Age 75 to 84 | 563 |
| Number Of Beneficiaries Age Greater 84 | 246 |
| Number Of Female Beneficiaries | 1327 |
| Number Of Male Beneficiaries | 665 |
| Number Of Non Hispanic White Beneficiaries | 1682 |
| Number Of Black or African American Beneficiaries | 111 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 158 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | 21 |
| Number Of Beneficiaries With Medicare Only Entitlement | 1564 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 428 |
| Percent Of With Atrial Fibrillation | 14 |
| Percent Of With Alzheimers Disease or Dementia | 13 |
| Percent Of With Asthma | 11 |
| Percent Of With Cancer | 17 |
| Percent Of With Heart Failure | 23 |
| Percent Of With Chronic Kidney Disease | 32 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 21 |
| Percent Of With Depression | 27 |
| Percent Of With Diabetes | 33 |
| Percent Of With Hyperlipidemia | 69 |
| Percent Of With Hypertension | 74 |
| Percent Of With Ischemic Heart Disease | 37 |
| Percent Of With Osteoporosis | 14 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 46 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 7 |
| Percent Of With Stroke | 7 |
| Average HCC Risk Score Of Beneficiaries | 1.4352 |