| National Provider Identifier [NPI]: | 1336180900 |
| Last Name Of The Provider | WAGNER |
| First Name Of The Provider | DIANE |
| Middle Initial Of The Provider | B |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1453 E BERT KOUNS LOOP |
| Street Address 2 Of The Provider | RADIOLOGY |
| City Of The Provider | SHREVEPORT |
| Zip Code Of The Provider | 711056800 |
| State Code Of The Provider | LA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 187 |
| Number Of Services | 7038 |
| Number Of Medicare Beneficiaries | 4160 |
| Total Submitted Charge Amount | 837803.9 |
| Total Medicare Allowed Amount | 191362.88 |
| Total Medicare Payment Amount | 151222.71 |
| Total Medicare Standardized Payment Amount | 159172.69 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 1 |
| Number Of Drug Services | 290 |
| Number Of Medicare Beneficiaries With Drug Services | 16 |
| Total Drug Submitted ChargeAmount | 2030 |
| Total Drug Medicare AllowedAmount | 644.81 |
| Total Drug Medicare PaymentAmount | 505.53 |
| Total Drug Medicare Standardized Payment Amount | 505.53 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 186 |
| Number Of Medical Services | 6748 |
| Number Of Medicare Beneficiaries With Medical Services | 4160 |
| Total Medical Submitted Charge Amount | 835773.9 |
| Total Medical Medicare Allowed Amount | 190718.07 |
| Total Medical Medicare Payment Amount | 150717.18 |
| Total Medical Medicare Standardized Payment Amount | 158667.16 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 635 |
| Number Of Beneficiaries Age 65 to 74 | 1699 |
| Number Of Beneficiaries Age 75 to 84 | 1231 |
| Number Of Beneficiaries Age Greater 84 | 595 |
| Number Of Female Beneficiaries | 2950 |
| Number Of Male Beneficiaries | 1210 |
| Number Of Non Hispanic White Beneficiaries | 2979 |
| Number Of Black or African American Beneficiaries | 1111 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 40 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | 17 |
| Number Of Beneficiaries With Medicare Only Entitlement | 2966 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 1194 |
| Percent Of With Atrial Fibrillation | 14 |
| Percent Of With Alzheimers Disease or Dementia | 19 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 14 |
| Percent Of With Heart Failure | 29 |
| Percent Of With Chronic Kidney Disease | 34 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 26 |
| Percent Of With Depression | 28 |
| Percent Of With Diabetes | 37 |
| Percent Of With Hyperlipidemia | 60 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 44 |
| Percent Of With Osteoporosis | 11 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 55 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 5 |
| Percent Of With Stroke | 8 |
| Average HCC Risk Score Of Beneficiaries | 1.5844 |