| National Provider Identifier [NPI]: | 1194789834 |
| Last Name Of The Provider | SETIAWAN |
| First Name Of The Provider | ANTHONY |
| Middle Initial Of The Provider | T |
| Credentials Of The Provider | MD |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 5323 HARRY HINES BLVD |
| Street Address 2 Of The Provider | |
| City Of The Provider | DALLAS |
| Zip Code Of The Provider | 753907208 |
| State Code Of The Provider | TX |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Diagnostic Radiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 39 |
| Number Of Services | 828 |
| Number Of Medicare Beneficiaries | 728 |
| Total Submitted Charge Amount | 125666 |
| Total Medicare Allowed Amount | 41310.7 |
| Total Medicare Payment Amount | 30468.53 |
| Total Medicare Standardized Payment Amount | 30576.35 |
| 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 | 39 |
| Number Of Medical Services | 828 |
| Number Of Medicare Beneficiaries With Medical Services | 728 |
| Total Medical Submitted Charge Amount | 125666 |
| Total Medical Medicare Allowed Amount | 41310.7 |
| Total Medical Medicare Payment Amount | 30468.53 |
| Total Medical Medicare Standardized Payment Amount | 30576.35 |
| Average Age Of Beneficiaries | 64 |
| Number Of Beneficiaries Age Less65 | 303 |
| Number Of Beneficiaries Age 65 to 74 | 289 |
| Number Of Beneficiaries Age 75 to 84 | 112 |
| Number Of Beneficiaries Age Greater 84 | 24 |
| Number Of Female Beneficiaries | 381 |
| Number Of Male Beneficiaries | 347 |
| Number Of Non Hispanic White Beneficiaries | 214 |
| Number Of Black or African American Beneficiaries | 315 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 172 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 370 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 358 |
| Percent Of With Atrial Fibrillation | 8 |
| Percent Of With Alzheimers Disease or Dementia | 14 |
| Percent Of With Asthma | 11 |
| Percent Of With Cancer | 21 |
| Percent Of With Heart Failure | 36 |
| Percent Of With Chronic Kidney Disease | 51 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 20 |
| Percent Of With Depression | 32 |
| Percent Of With Diabetes | 49 |
| Percent Of With Hyperlipidemia | 61 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 40 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 46 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 8 |
| Percent Of With Stroke | 8 |
| Average HCC Risk Score Of Beneficiaries | 2.2411 |