| National Provider Identifier [NPI]: | 1245396860 |
| Last Name Of The Provider | MOULTON |
| First Name Of The Provider | RUSSEL |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | M.S., PSYCHOLOGY |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 55684 230TH ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | GLENWOOD |
| Zip Code Of The Provider | 515346192 |
| State Code Of The Provider | IA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Psychologist (billing independently) |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 1 |
| Number Of Services | 558.5 |
| Number Of Medicare Beneficiaries | 269 |
| Total Submitted Charge Amount | 94150 |
| Total Medicare Allowed Amount | 43769.68 |
| Total Medicare Payment Amount | 30491.05 |
| Total Medicare Standardized Payment Amount | 14625.42 |
| 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 | 1 |
| Number Of Medical Services | 558.5 |
| Number Of Medicare Beneficiaries With Medical Services | 269 |
| Total Medical Submitted Charge Amount | 94150 |
| Total Medical Medicare Allowed Amount | 43769.68 |
| Total Medical Medicare Payment Amount | 30491.05 |
| Total Medical Medicare Standardized Payment Amount | 14625.42 |
| Average Age Of Beneficiaries | 46 |
| Number Of Beneficiaries Age Less65 | 242 |
| Number Of Beneficiaries Age 65 to 74 | |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 122 |
| Number Of Male Beneficiaries | 147 |
| Number Of Non Hispanic White Beneficiaries | 255 |
| 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 | 0 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 269 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | 4 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 6 |
| Percent Of With Chronic Kidney Disease | 8 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 7 |
| Percent Of With Depression | 36 |
| Percent Of With Diabetes | 17 |
| Percent Of With Hyperlipidemia | 26 |
| Percent Of With Hypertension | 30 |
| Percent Of With Ischemic Heart Disease | |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 11 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 16 |
| Percent Of With Stroke | 0 |
| Average HCC Risk Score Of Beneficiaries | 0.7625 |