| National Provider Identifier [NPI]: | 1205824406 |
| Last Name Of The Provider | FONSECA |
| First Name Of The Provider | LUVIANCA |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4255 W 63RD ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | CHICAGO |
| Zip Code Of The Provider | 606295041 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 29 |
| Number Of Services | 376 |
| Number Of Medicare Beneficiaries | 87 |
| Total Submitted Charge Amount | 35932 |
| Total Medicare Allowed Amount | 27393.67 |
| Total Medicare Payment Amount | 18405.18 |
| Total Medicare Standardized Payment Amount | 17691.78 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 5 |
| Number Of Drug Services | 29 |
| Number Of Medicare Beneficiaries With Drug Services | 26 |
| Total Drug Submitted ChargeAmount | 1091.5 |
| Total Drug Medicare AllowedAmount | 409.53 |
| Total Drug Medicare PaymentAmount | 394.74 |
| Total Drug Medicare Standardized Payment Amount | 394.74 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 24 |
| Number Of Medical Services | 347 |
| Number Of Medicare Beneficiaries With Medical Services | 87 |
| Total Medical Submitted Charge Amount | 34840.5 |
| Total Medical Medicare Allowed Amount | 26984.14 |
| Total Medical Medicare Payment Amount | 18010.44 |
| Total Medical Medicare Standardized Payment Amount | 17297.04 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 50 |
| Number Of Beneficiaries Age 75 to 84 | 16 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 60 |
| Number Of Male Beneficiaries | 27 |
| 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 | 45 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 42 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 25 |
| Percent Of With Diabetes | 40 |
| Percent Of With Hyperlipidemia | 68 |
| Percent Of With Hypertension | 66 |
| Percent Of With Ischemic Heart Disease | 15 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 18 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 0 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.9557 |