| National Provider Identifier [NPI]: | 1710936497 |
| Last Name Of The Provider | MANNESS |
| First Name Of The Provider | WAYNE |
| Middle Initial Of The Provider | K |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1709 JUMER DR |
| Street Address 2 Of The Provider | SUITE B |
| City Of The Provider | BLOOMINGTON |
| Zip Code Of The Provider | 617040914 |
| 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 | 44 |
| Number Of Services | 2580 |
| Number Of Medicare Beneficiaries | 998 |
| Total Submitted Charge Amount | 851183 |
| Total Medicare Allowed Amount | 156145.34 |
| Total Medicare Payment Amount | 118549.67 |
| Total Medicare Standardized Payment Amount | 127567.05 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 1 |
| Number Of Drug Services | 1114 |
| Number Of Medicare Beneficiaries With Drug Services | 83 |
| Total Drug Submitted ChargeAmount | 12441 |
| Total Drug Medicare AllowedAmount | 2475.89 |
| Total Drug Medicare PaymentAmount | 1910.63 |
| Total Drug Medicare Standardized Payment Amount | 1910.63 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 43 |
| Number Of Medical Services | 1466 |
| Number Of Medicare Beneficiaries With Medical Services | 998 |
| Total Medical Submitted Charge Amount | 838742 |
| Total Medical Medicare Allowed Amount | 153669.45 |
| Total Medical Medicare Payment Amount | 116639.04 |
| Total Medical Medicare Standardized Payment Amount | 125656.42 |
| Average Age Of Beneficiaries | 74 |
| Number Of Beneficiaries Age Less65 | 108 |
| Number Of Beneficiaries Age 65 to 74 | 399 |
| Number Of Beneficiaries Age 75 to 84 | 346 |
| Number Of Beneficiaries Age Greater 84 | 145 |
| Number Of Female Beneficiaries | 606 |
| Number Of Male Beneficiaries | 392 |
| Number Of Non Hispanic White Beneficiaries | 876 |
| Number Of Black or African American Beneficiaries | 43 |
| Number Of AsianPacific Islander Beneficiaries | 23 |
| Number Of Hispanic Beneficiaries | 40 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | 16 |
| Number Of Beneficiaries With Medicare Only Entitlement | 905 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 93 |
| Percent Of With Atrial Fibrillation | 15 |
| Percent Of With Alzheimers Disease or Dementia | 14 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 17 |
| Percent Of With Heart Failure | 14 |
| Percent Of With Chronic Kidney Disease | 20 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 13 |
| Percent Of With Depression | 25 |
| Percent Of With Diabetes | 26 |
| Percent Of With Hyperlipidemia | 55 |
| Percent Of With Hypertension | 67 |
| Percent Of With Ischemic Heart Disease | 31 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 57 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 6 |
| Percent Of With Stroke | 16 |
| Average HCC Risk Score Of Beneficiaries | 1.219 |