| National Provider Identifier [NPI]: | 1891745865 |
| Last Name Of The Provider | GUSTAFSON |
| First Name Of The Provider | KEVIN |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4801 W 81ST ST |
| Street Address 2 Of The Provider | SUITE 108 |
| City Of The Provider | BLOOMINGTON |
| Zip Code Of The Provider | 554371111 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 104 |
| Number Of Services | 4352 |
| Number Of Medicare Beneficiaries | 1777 |
| Total Submitted Charge Amount | 404586.06 |
| Total Medicare Allowed Amount | 129266.23 |
| Total Medicare Payment Amount | 97270.95 |
| Total Medicare Standardized Payment Amount | 102270.46 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 2 |
| Number Of Drug Services | 1641 |
| Number Of Medicare Beneficiaries With Drug Services | 41 |
| Total Drug Submitted ChargeAmount | 1203.06 |
| Total Drug Medicare AllowedAmount | 892.99 |
| Total Drug Medicare PaymentAmount | 691.44 |
| Total Drug Medicare Standardized Payment Amount | 691.44 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 102 |
| Number Of Medical Services | 2711 |
| Number Of Medicare Beneficiaries With Medical Services | 1777 |
| Total Medical Submitted Charge Amount | 403383 |
| Total Medical Medicare Allowed Amount | 128373.24 |
| Total Medical Medicare Payment Amount | 96579.51 |
| Total Medical Medicare Standardized Payment Amount | 101579.02 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 478 |
| Number Of Beneficiaries Age 65 to 74 | 394 |
| Number Of Beneficiaries Age 75 to 84 | 492 |
| Number Of Beneficiaries Age Greater 84 | 413 |
| Number Of Female Beneficiaries | 1049 |
| Number Of Male Beneficiaries | 728 |
| Number Of Non Hispanic White Beneficiaries | 1595 |
| Number Of Black or African American Beneficiaries | 99 |
| Number Of AsianPacific Islander Beneficiaries | 18 |
| Number Of Hispanic Beneficiaries | 18 |
| Number Of American Indian Alaska Native Beneficiaries | 22 |
| Number Of Beneficiaries With Race Not Else where Classified | 25 |
| Number Of Beneficiaries With Medicare Only Entitlement | 1238 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 539 |
| Percent Of With Atrial Fibrillation | 19 |
| Percent Of With Alzheimers Disease or Dementia | 22 |
| Percent Of With Asthma | 15 |
| Percent Of With Cancer | 15 |
| Percent Of With Heart Failure | 26 |
| Percent Of With Chronic Kidney Disease | 37 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 20 |
| Percent Of With Depression | 42 |
| Percent Of With Diabetes | 29 |
| Percent Of With Hyperlipidemia | 52 |
| Percent Of With Hypertension | 71 |
| Percent Of With Ischemic Heart Disease | 38 |
| Percent Of With Osteoporosis | 12 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 38 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 15 |
| Percent Of With Stroke | 13 |
| Average HCC Risk Score Of Beneficiaries | 1.7091 |