| National Provider Identifier [NPI]: | 1144364605 |
| Last Name Of The Provider | SUSANTO |
| First Name Of The Provider | DANIEL |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 19020 33RD AVE W |
| Street Address 2 Of The Provider | STE 210 |
| City Of The Provider | LYNNWOOD |
| Zip Code Of The Provider | 980364746 |
| State Code Of The Provider | WA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 58 |
| Number Of Services | 2692 |
| Number Of Medicare Beneficiaries | 1439 |
| Total Submitted Charge Amount | 702926.26 |
| Total Medicare Allowed Amount | 185011.84 |
| Total Medicare Payment Amount | 137818.44 |
| Total Medicare Standardized Payment Amount | 134582.64 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 3 |
| Number Of Drug Services | 697 |
| Number Of Medicare Beneficiaries With Drug Services | 27 |
| Total Drug Submitted ChargeAmount | 1181.3 |
| Total Drug Medicare AllowedAmount | 883.63 |
| Total Drug Medicare PaymentAmount | 669.52 |
| Total Drug Medicare Standardized Payment Amount | 669.52 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 55 |
| Number Of Medical Services | 1995 |
| Number Of Medicare Beneficiaries With Medical Services | 1439 |
| Total Medical Submitted Charge Amount | 701744.96 |
| Total Medical Medicare Allowed Amount | 184128.21 |
| Total Medical Medicare Payment Amount | 137148.92 |
| Total Medical Medicare Standardized Payment Amount | 133913.12 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 247 |
| Number Of Beneficiaries Age 65 to 74 | 578 |
| Number Of Beneficiaries Age 75 to 84 | 419 |
| Number Of Beneficiaries Age Greater 84 | 195 |
| Number Of Female Beneficiaries | 802 |
| Number Of Male Beneficiaries | 637 |
| Number Of Non Hispanic White Beneficiaries | 1229 |
| Number Of Black or African American Beneficiaries | 51 |
| Number Of AsianPacific Islander Beneficiaries | 75 |
| Number Of Hispanic Beneficiaries | 31 |
| Number Of American Indian Alaska Native Beneficiaries | 25 |
| Number Of Beneficiaries With Race Not Else where Classified | 28 |
| Number Of Beneficiaries With Medicare Only Entitlement | 1137 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 302 |
| Percent Of With Atrial Fibrillation | 13 |
| Percent Of With Alzheimers Disease or Dementia | 15 |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | 14 |
| Percent Of With Heart Failure | 17 |
| Percent Of With Chronic Kidney Disease | 25 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 14 |
| Percent Of With Depression | 31 |
| Percent Of With Diabetes | 26 |
| Percent Of With Hyperlipidemia | 52 |
| Percent Of With Hypertension | 66 |
| Percent Of With Ischemic Heart Disease | 31 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 47 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 7 |
| Percent Of With Stroke | 23 |
| Average HCC Risk Score Of Beneficiaries | 1.3803 |