| National Provider Identifier [NPI]: | 1326006396 |
| Last Name Of The Provider | SAMPLE |
| First Name Of The Provider | MICHAEL |
| Middle Initial Of The Provider | W |
| Credentials Of The Provider | DC |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 51 N MAIN ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | MANTENO |
| Zip Code Of The Provider | 609501534 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Chiropractic |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 1 |
| Number Of Services | 300 |
| Number Of Medicare Beneficiaries | 81 |
| Total Submitted Charge Amount | 14700 |
| Total Medicare Allowed Amount | 12137.85 |
| Total Medicare Payment Amount | 9128.53 |
| Total Medicare Standardized Payment Amount | 9204.55 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 1 |
| Number Of Medical Services | 300 |
| Number Of Medicare Beneficiaries With Medical Services | 81 |
| Total Medical Submitted Charge Amount | 14700 |
| Total Medical Medicare Allowed Amount | 12137.85 |
| Total Medical Medicare Payment Amount | 9128.53 |
| Total Medical Medicare Standardized Payment Amount | 9204.55 |
| Average Age Of Beneficiaries | 76 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 38 |
| Number Of Beneficiaries Age 75 to 84 | 26 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 43 |
| Number Of Male Beneficiaries | 38 |
| 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 | |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | 15 |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | 17 |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | |
| Percent Of With Diabetes | 28 |
| Percent Of With Hyperlipidemia | 64 |
| Percent Of With Hypertension | 73 |
| Percent Of With Ischemic Heart Disease | 42 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 40 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 0 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.913 |