| National Provider Identifier [NPI]: | 1609078559 |
| Last Name Of The Provider | DICKERSON |
| First Name Of The Provider | TINA |
| Middle Initial Of The Provider | D |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2601 KELLEY POINTE PKWY |
| Street Address 2 Of The Provider | STE. 101 |
| City Of The Provider | EDMOND |
| Zip Code Of The Provider | 730132995 |
| State Code Of The Provider | OK |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 22 |
| Number Of Services | 2855 |
| Number Of Medicare Beneficiaries | 1246 |
| Total Submitted Charge Amount | 344594 |
| Total Medicare Allowed Amount | 131084.76 |
| Total Medicare Payment Amount | 110629.51 |
| Total Medicare Standardized Payment Amount | 123618.48 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 1 |
| Number Of Drug Services | 240 |
| Number Of Medicare Beneficiaries With Drug Services | 12 |
| Total Drug Submitted ChargeAmount | 769 |
| Total Drug Medicare AllowedAmount | 470.08 |
| Total Drug Medicare PaymentAmount | 368.59 |
| Total Drug Medicare Standardized Payment Amount | 368.59 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 21 |
| Number Of Medical Services | 2615 |
| Number Of Medicare Beneficiaries With Medical Services | 1246 |
| Total Medical Submitted Charge Amount | 343825 |
| Total Medical Medicare Allowed Amount | 130614.68 |
| Total Medical Medicare Payment Amount | 110260.92 |
| Total Medical Medicare Standardized Payment Amount | 123249.89 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 61 |
| Number Of Beneficiaries Age 65 to 74 | 791 |
| Number Of Beneficiaries Age 75 to 84 | 345 |
| Number Of Beneficiaries Age Greater 84 | 49 |
| Number Of Female Beneficiaries | |
| Number Of Male Beneficiaries | |
| Number Of Non Hispanic White Beneficiaries | 1166 |
| Number Of Black or African American Beneficiaries | 26 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 23 |
| Number Of Beneficiaries With Race Not Else where Classified | 13 |
| Number Of Beneficiaries With Medicare Only Entitlement | 1194 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 52 |
| Percent Of With Atrial Fibrillation | 5 |
| Percent Of With Alzheimers Disease or Dementia | 4 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 15 |
| Percent Of With Heart Failure | 8 |
| Percent Of With Chronic Kidney Disease | 8 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 6 |
| Percent Of With Depression | 15 |
| Percent Of With Diabetes | 18 |
| Percent Of With Hyperlipidemia | 49 |
| Percent Of With Hypertension | 57 |
| Percent Of With Ischemic Heart Disease | 21 |
| Percent Of With Osteoporosis | 11 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 42 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 2 |
| Percent Of With Stroke | 2 |
| Average HCC Risk Score Of Beneficiaries | 0.7205 |