| National Provider Identifier [NPI]: | 1639175003 |
| Last Name Of The Provider | MANTZ |
| First Name Of The Provider | DONALD |
| Middle Initial Of The Provider | C |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1130 NORTH 204TH STREET |
| Street Address 2 Of The Provider | |
| City Of The Provider | ELKHORN |
| Zip Code Of The Provider | 68022 |
| State Code Of The Provider | NE |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 75 |
| Number Of Services | 1708 |
| Number Of Medicare Beneficiaries | 173 |
| Total Submitted Charge Amount | 129946 |
| Total Medicare Allowed Amount | 61461.32 |
| Total Medicare Payment Amount | 43986.55 |
| Total Medicare Standardized Payment Amount | 47512.02 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 11 |
| Number Of Drug Services | 310 |
| Number Of Medicare Beneficiaries With Drug Services | 74 |
| Total Drug Submitted ChargeAmount | 10268 |
| Total Drug Medicare AllowedAmount | 5427.04 |
| Total Drug Medicare PaymentAmount | 5223.29 |
| Total Drug Medicare Standardized Payment Amount | 5223.29 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 64 |
| Number Of Medical Services | 1398 |
| Number Of Medicare Beneficiaries With Medical Services | 173 |
| Total Medical Submitted Charge Amount | 119678 |
| Total Medical Medicare Allowed Amount | 56034.28 |
| Total Medical Medicare Payment Amount | 38763.26 |
| Total Medical Medicare Standardized Payment Amount | 42288.73 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 19 |
| Number Of Beneficiaries Age 65 to 74 | 88 |
| Number Of Beneficiaries Age 75 to 84 | 48 |
| Number Of Beneficiaries Age Greater 84 | 18 |
| Number Of Female Beneficiaries | 80 |
| Number Of Male Beneficiaries | 93 |
| Number Of Non Hispanic White Beneficiaries | |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 154 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 19 |
| Percent Of With Atrial Fibrillation | 12 |
| Percent Of With Alzheimers Disease or Dementia | 8 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 9 |
| Percent Of With Chronic Kidney Disease | 22 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 18 |
| Percent Of With Depression | 27 |
| Percent Of With Diabetes | 33 |
| Percent Of With Hyperlipidemia | 58 |
| Percent Of With Hypertension | 64 |
| Percent Of With Ischemic Heart Disease | 25 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 33 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.0736 |