| National Provider Identifier [NPI]: | 1346201209 |
| Last Name Of The Provider | HUSSONG |
| First Name Of The Provider | JERRY |
| Middle Initial Of The Provider | W |
| Credentials Of The Provider | DDS MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 500 S CHIPETA WAY |
| Street Address 2 Of The Provider | |
| City Of The Provider | SALT LAKE CITY |
| Zip Code Of The Provider | 841081221 |
| State Code Of The Provider | UT |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Pathology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 21 |
| Number Of Services | 382 |
| Number Of Medicare Beneficiaries | 160 |
| Total Submitted Charge Amount | 60421.44 |
| Total Medicare Allowed Amount | 22661.52 |
| Total Medicare Payment Amount | 16787.98 |
| Total Medicare Standardized Payment Amount | 17152.67 |
| 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 | 21 |
| Number Of Medical Services | 382 |
| Number Of Medicare Beneficiaries With Medical Services | 160 |
| Total Medical Submitted Charge Amount | 60421.44 |
| Total Medical Medicare Allowed Amount | 22661.52 |
| Total Medical Medicare Payment Amount | 16787.98 |
| Total Medical Medicare Standardized Payment Amount | 17152.67 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 22 |
| Number Of Beneficiaries Age 65 to 74 | 81 |
| Number Of Beneficiaries Age 75 to 84 | 46 |
| Number Of Beneficiaries Age Greater 84 | 11 |
| Number Of Female Beneficiaries | 68 |
| Number Of Male Beneficiaries | 92 |
| Number Of Non Hispanic White Beneficiaries | 138 |
| 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 | 144 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 16 |
| Percent Of With Atrial Fibrillation | 11 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | 13 |
| Percent Of With Heart Failure | 25 |
| Percent Of With Chronic Kidney Disease | 41 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 18 |
| Percent Of With Depression | 37 |
| Percent Of With Diabetes | 29 |
| Percent Of With Hyperlipidemia | 41 |
| Percent Of With Hypertension | 62 |
| Percent Of With Ischemic Heart Disease | 35 |
| Percent Of With Osteoporosis | 11 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 34 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 2.016 |