| National Provider Identifier [NPI]: | 1659545184 |
| Last Name Of The Provider | WAGNER |
| First Name Of The Provider | ELIZABETH |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | DMD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 100 E LEHIGH AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | PHILADELPHIA |
| Zip Code Of The Provider | 191251012 |
| State Code Of The Provider | PA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Maxillofacial Surgery |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 17 |
| Number Of Services | 184 |
| Number Of Medicare Beneficiaries | 116 |
| Total Submitted Charge Amount | 85049 |
| Total Medicare Allowed Amount | 18795.82 |
| Total Medicare Payment Amount | 13922.55 |
| Total Medicare Standardized Payment Amount | 12839.19 |
| 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 | 17 |
| Number Of Medical Services | 184 |
| Number Of Medicare Beneficiaries With Medical Services | 116 |
| Total Medical Submitted Charge Amount | 85049 |
| Total Medical Medicare Allowed Amount | 18795.82 |
| Total Medical Medicare Payment Amount | 13922.55 |
| Total Medical Medicare Standardized Payment Amount | 12839.19 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 16 |
| Number Of Beneficiaries Age 65 to 74 | 45 |
| Number Of Beneficiaries Age 75 to 84 | 29 |
| Number Of Beneficiaries Age Greater 84 | 26 |
| Number Of Female Beneficiaries | 67 |
| Number Of Male Beneficiaries | 49 |
| 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 | 101 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 15 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | 13 |
| Percent Of With Asthma | |
| Percent Of With Cancer | 17 |
| Percent Of With Heart Failure | 18 |
| Percent Of With Chronic Kidney Disease | 22 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 10 |
| Percent Of With Depression | 28 |
| Percent Of With Diabetes | 29 |
| Percent Of With Hyperlipidemia | 59 |
| Percent Of With Hypertension | 65 |
| Percent Of With Ischemic Heart Disease | 32 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 41 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.4678 |