| National Provider Identifier [NPI]: | 1184648131 |
| Last Name Of The Provider | MEJIA |
| First Name Of The Provider | ETIENNE |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 277 ALTENHOFEN DR |
| Street Address 2 Of The Provider | |
| City Of The Provider | APPLETON |
| Zip Code Of The Provider | 549138401 |
| State Code Of The Provider | WI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Orthopedic Surgery |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 24 |
| Number Of Services | 330 |
| Number Of Medicare Beneficiaries | 58 |
| Total Submitted Charge Amount | 177309 |
| Total Medicare Allowed Amount | 37596.02 |
| Total Medicare Payment Amount | 28513.45 |
| Total Medicare Standardized Payment Amount | 30102.54 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 3 |
| Number Of Drug Services | 96 |
| Number Of Medicare Beneficiaries With Drug Services | 19 |
| Total Drug Submitted ChargeAmount | 12876 |
| Total Drug Medicare AllowedAmount | 7954.95 |
| Total Drug Medicare PaymentAmount | 6092.69 |
| Total Drug Medicare Standardized Payment Amount | 6092.69 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 21 |
| Number Of Medical Services | 234 |
| Number Of Medicare Beneficiaries With Medical Services | 58 |
| Total Medical Submitted Charge Amount | 164433 |
| Total Medical Medicare Allowed Amount | 29641.07 |
| Total Medical Medicare Payment Amount | 22420.76 |
| Total Medical Medicare Standardized Payment Amount | 24009.85 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 36 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 32 |
| Number Of Male Beneficiaries | 26 |
| 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 | 0 |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 22 |
| Percent Of With Diabetes | |
| Percent Of With Hyperlipidemia | 55 |
| Percent Of With Hypertension | 47 |
| Percent Of With Ischemic Heart Disease | 21 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 66 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 0 |
| Percent Of With Stroke | 0 |
| Average HCC Risk Score Of Beneficiaries | 0.707 |