| National Provider Identifier [NPI]: | 1346209020 |
| Last Name Of The Provider | JOHNSON |
| First Name Of The Provider | WALLACE |
| Middle Initial Of The Provider | S |
| Credentials Of The Provider | O.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 702 10TH ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | WORTHINGTON |
| Zip Code Of The Provider | 561872767 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Optometry |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 19 |
| Number Of Services | 4114 |
| Number Of Medicare Beneficiaries | 475 |
| Total Submitted Charge Amount | 84901.75 |
| Total Medicare Allowed Amount | 80133.88 |
| Total Medicare Payment Amount | 57572.06 |
| Total Medicare Standardized Payment Amount | 65202.14 |
| 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 | 19 |
| Number Of Medical Services | 4114 |
| Number Of Medicare Beneficiaries With Medical Services | 475 |
| Total Medical Submitted Charge Amount | 84901.75 |
| Total Medical Medicare Allowed Amount | 80133.88 |
| Total Medical Medicare Payment Amount | 57572.06 |
| Total Medical Medicare Standardized Payment Amount | 65202.14 |
| Average Age Of Beneficiaries | 74 |
| Number Of Beneficiaries Age Less65 | 69 |
| Number Of Beneficiaries Age 65 to 74 | 144 |
| Number Of Beneficiaries Age 75 to 84 | 170 |
| Number Of Beneficiaries Age Greater 84 | 92 |
| Number Of Female Beneficiaries | 303 |
| Number Of Male Beneficiaries | 172 |
| Number Of Non Hispanic White Beneficiaries | 450 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 12 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 383 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 92 |
| Percent Of With Atrial Fibrillation | 11 |
| Percent Of With Alzheimers Disease or Dementia | 3 |
| Percent Of With Asthma | 4 |
| Percent Of With Cancer | 9 |
| Percent Of With Heart Failure | 14 |
| Percent Of With Chronic Kidney Disease | 19 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 10 |
| Percent Of With Depression | 17 |
| Percent Of With Diabetes | 33 |
| Percent Of With Hyperlipidemia | 49 |
| Percent Of With Hypertension | 61 |
| Percent Of With Ischemic Heart Disease | 27 |
| Percent Of With Osteoporosis | 6 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 27 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 5 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.0496 |