| National Provider Identifier [NPI]: | 1245274141 |
| Last Name Of The Provider | DIETRICH |
| First Name Of The Provider | TERRY |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1405 MILL ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | NEW LONDON |
| Zip Code Of The Provider | 549612155 |
| State Code Of The Provider | WI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Orthopedic Surgery |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 34 |
| Number Of Services | 187 |
| Number Of Medicare Beneficiaries | 82 |
| Total Submitted Charge Amount | 76228.2 |
| Total Medicare Allowed Amount | 21028.93 |
| Total Medicare Payment Amount | 15513.56 |
| Total Medicare Standardized Payment Amount | 16532.23 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 3 |
| Number Of Drug Services | 26 |
| Number Of Medicare Beneficiaries With Drug Services | 19 |
| Total Drug Submitted ChargeAmount | 999 |
| Total Drug Medicare AllowedAmount | 659.75 |
| Total Drug Medicare PaymentAmount | 512.84 |
| Total Drug Medicare Standardized Payment Amount | 512.84 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 31 |
| Number Of Medical Services | 161 |
| Number Of Medicare Beneficiaries With Medical Services | 82 |
| Total Medical Submitted Charge Amount | 75229.2 |
| Total Medical Medicare Allowed Amount | 20369.18 |
| Total Medical Medicare Payment Amount | 15000.72 |
| Total Medical Medicare Standardized Payment Amount | 16019.39 |
| Average Age Of Beneficiaries | 67 |
| Number Of Beneficiaries Age Less65 | 30 |
| Number Of Beneficiaries Age 65 to 74 | 26 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 45 |
| Number Of Male Beneficiaries | 37 |
| Number Of Non Hispanic White Beneficiaries | |
| 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 | 56 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 26 |
| Percent Of With Atrial Fibrillation | 17 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 13 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 22 |
| Percent Of With Chronic Kidney Disease | 22 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 15 |
| Percent Of With Depression | 29 |
| Percent Of With Diabetes | 35 |
| Percent Of With Hyperlipidemia | 62 |
| Percent Of With Hypertension | 70 |
| Percent Of With Ischemic Heart Disease | 23 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 63 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.2496 |