| National Provider Identifier [NPI]: | 1023091824 |
| Last Name Of The Provider | FOLLANSBEE |
| First Name Of The Provider | JEFFREY |
| Middle Initial Of The Provider | T |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 252 MCHENRY ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | BURLINGTON |
| Zip Code Of The Provider | 531051828 |
| State Code Of The Provider | WI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Interventional Pain Management |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 31 |
| Number Of Services | 643 |
| Number Of Medicare Beneficiaries | 89 |
| Total Submitted Charge Amount | 241966.47 |
| Total Medicare Allowed Amount | 47129.86 |
| Total Medicare Payment Amount | 35998.85 |
| Total Medicare Standardized Payment Amount | 36851.26 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 3 |
| Number Of Drug Services | 128 |
| Number Of Medicare Beneficiaries With Drug Services | 12 |
| Total Drug Submitted ChargeAmount | 3279 |
| Total Drug Medicare AllowedAmount | 1672.67 |
| Total Drug Medicare PaymentAmount | 1311.26 |
| Total Drug Medicare Standardized Payment Amount | 1311.26 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 28 |
| Number Of Medical Services | 515 |
| Number Of Medicare Beneficiaries With Medical Services | 89 |
| Total Medical Submitted Charge Amount | 238687.47 |
| Total Medical Medicare Allowed Amount | 45457.19 |
| Total Medical Medicare Payment Amount | 34687.59 |
| Total Medical Medicare Standardized Payment Amount | 35540 |
| Average Age Of Beneficiaries | 52 |
| Number Of Beneficiaries Age Less65 | 70 |
| Number Of Beneficiaries Age 65 to 74 | |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 45 |
| Number Of Male Beneficiaries | 44 |
| Number Of Non Hispanic White Beneficiaries | 76 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 0 |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | 0 |
| Number Of Beneficiaries With Medicare Only Entitlement | 27 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 62 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 21 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | 15 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 12 |
| Percent Of With Depression | 49 |
| Percent Of With Diabetes | 18 |
| Percent Of With Hyperlipidemia | 39 |
| Percent Of With Hypertension | 52 |
| Percent Of With Ischemic Heart Disease | 18 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 54 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 26 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.1974 |