| National Provider Identifier [NPI]: | 1770560542 |
| Last Name Of The Provider | LY |
| First Name Of The Provider | JUSTIN |
| Middle Initial Of The Provider | Q |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2829 BABCOCK RD |
| Street Address 2 Of The Provider | STE 215 |
| City Of The Provider | SAN ANTONIO |
| Zip Code Of The Provider | 782296028 |
| 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 | 74 |
| Number Of Services | 1013 |
| Number Of Medicare Beneficiaries | 394 |
| Total Submitted Charge Amount | 55522 |
| Total Medicare Allowed Amount | 20539.83 |
| Total Medicare Payment Amount | 14698.59 |
| Total Medicare Standardized Payment Amount | 14303.42 |
| Drug Suppress Indicator | * |
| Number Of HCPCS Associated With Drug Services | |
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| Number Of Medicare Beneficiaries With Drug Services | |
| Total Drug Submitted ChargeAmount | |
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| Medical SuppressIndicator | # |
| Number Of HCPCS Associated With MedicalServices | |
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| Number Of Medicare Beneficiaries With Medical Services | |
| Total Medical Submitted Charge Amount | |
| Total Medical Medicare Allowed Amount | |
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| Average Age Of Beneficiaries | 75 |
| Number Of Beneficiaries Age Less65 | 34 |
| Number Of Beneficiaries Age 65 to 74 | 154 |
| Number Of Beneficiaries Age 75 to 84 | 135 |
| Number Of Beneficiaries Age Greater 84 | 71 |
| Number Of Female Beneficiaries | 233 |
| Number Of Male Beneficiaries | 161 |
| Number Of Non Hispanic White Beneficiaries | 299 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 35 |
| Number Of Hispanic Beneficiaries | 39 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 327 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 67 |
| Percent Of With Atrial Fibrillation | 27 |
| Percent Of With Alzheimers Disease or Dementia | 13 |
| Percent Of With Asthma | 11 |
| Percent Of With Cancer | 14 |
| Percent Of With Heart Failure | 34 |
| Percent Of With Chronic Kidney Disease | 39 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 24 |
| Percent Of With Depression | 27 |
| Percent Of With Diabetes | 27 |
| Percent Of With Hyperlipidemia | 59 |
| Percent Of With Hypertension | 72 |
| Percent Of With Ischemic Heart Disease | 45 |
| Percent Of With Osteoporosis | 12 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 37 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 5 |
| Percent Of With Stroke | 10 |
| Average HCC Risk Score Of Beneficiaries | 1.9295 |