Why are Medicare and Medicaid shown separately instead of combined?

They come from two different CMS data sources with no shared claim identifier, so they can't be reconciled into one number without double-counting or guessing. Every table and chart on this page keeps them fully separate.

Why is there no private/commercial revenue figure?

Private and commercial payer data comes from Transparency in Coverage files, which only publish negotiated rates — not claims or utilization volume. Without a volume figure, no revenue number can be computed for any provider from that data.

What does "Rank" mean in the Competitive Analysis & Benchmarks tables?

For a given CPT/HCPCS code, it's this provider's position by claims volume among all providers billing that same code at that geography level (State, National, or South Carolina for Medicaid) — rank 1 means the highest claims volume for that code.

Why is the Medicaid comparison limited to South Carolina only?

Medicaid is administered per-state with no single national fee schedule, so a state or national comparison the way Medicare has one isn't available. South Carolina (this provider's own state) is the only grouping that's conceptually meaningful.

Why are the numbers rounded to the nearest 10?

To avoid implying more precision than the underlying data supports at a single-provider level. Ratios are kept precise since they're a relative comparison, not a volume or dollar figure.

How current is this data?

The Medicare and Medicaid tables are both single current snapshots, not refreshed on a recurring schedule yet.

Prisma Health-upstate (NPI 1336695436)

Key Findings

Field	Value
Entity Type	Organization
Organization	Prisma Health-upstate
Address	29 N Academy St
City	Greenville
State	SC
ZIP	29601
Taxonomy	Developmental Disabilities Clinic/Center
NPI Enumerated	August 29, 2016

Payer Source	Total Paid
Medicaid	$19.7M
Medicare	$0

PRISMA HEALTH-UPSTATE reports no Medicare billing on file and is effectively a single-payer Medicaid provider at this scale, with total Medicaid revenue of $19.7M. The absence of Medicare activity means downstream analyses should focus on Medicaid utilization and reimbursement risk rather than dual-payer dynamics.

Revenue is extremely concentrated in a handful of therapy codes: the top 3 Medicaid codes account for 99.9% of this provider's total Medicaid revenue, signaling dependence on a narrow set of services for financial performance. That concentration creates sensitivity to policy, rate, or utilization changes for those specific codes.

92507 is the single largest Medicaid revenue driver with 105.9K claims, $88 avg paid/claim, and $9.3M revenue (47.3% of the provider's Medicaid revenue). This code’s state rank (#3 of 339, 99th percentile) is labeled an "extreme outlier," indicating PRISMA is a dominant statewide provider of the speech/communication services captured by 92507.

97530 is the second major driver with 89.7K claims, $80 avg paid/claim, and $7.2M revenue (36.4% of Medicaid revenue). Its position as #4 of 345 providers in-state (99th percentile) and the "extreme outlier" designation show similarly outsized scale in direct therapeutic activity sessions relative to peers.

97110 contributes 43.6K claims, $73 avg paid/claim, and $3.2M revenue (16.2% of Medicaid revenue) and ranks #12 of 285 providers in-state (96th percentile). This code’s placement as "notably above typical" state volume indicates PRISMA is also a major provider of therapeutic exercise services, rounding out a therapy-dominant service mix.

The mix of 92507 (speech/communication), 97530 (therapeutic activities), and 97110 (therapeutic exercise) suggests PRISMA operates primarily as a high-volume therapy center focused on communication and rehabilitation services, consistent with its Developmental Disabilities Clinic/Center taxonomy. High claim counts for time-based therapy codes imply substantial throughput and capacity devoted to repeated, direct contact interventions.

Given the concentration in three therapy codes and the labeled outlier status for the top two, PRISMA’s competitive standing in-state is dominant for speech and therapy services covered by Medicaid, but this also concentrates operational and reimbursement risk in those service lines. Any changes in coverage, prior authorization, or unit rates for 92507 or 97530 would likely have a material impact on reported Medicaid revenue.

The provider’s NPI was enumerated on 2016-08-29 (~10 years ago), indicating roughly a decade of enrollment during which it has established these high-volume therapy patterns. Tenure combined with extreme-state-level volume suggests these utilization patterns are established operations rather than transient spikes.

Medicaid: Complete Services Breakdown

Every CPT/HCPCS code this provider has billed to Medicaid, with claims volume, average payment, and total revenue.

10 rows

CPT/HCPCS Code	Description	Claims	Avg Paid	Revenue
92507	The provider treats a patient with communication and hearing difficulties by directly interacting with the patient. He assesses the patient with impairment in his ability to make sounds, along with…	105,870	$90	$9.3M
97530	The provider uses various activities during direct contact with the patient to improve the patient’s functional performance. Use this code for each 15 minutes of activity.	89,700	$80	$7.2M
97110	Therapeutic exercise is a form of physical therapy that utilizes specially designed exercises and activities to help patients gain better mobility and fitness levels. Normally used on patients with…	43,640	$70	$3.2M
92526	The provider treats a swallowing disorder through medications, rehabilitation, or a feeding tube, to identify the cause of improper functioning.	240	$40	$8.8K
97162	The provider, typically a physical therapist, conducts a physical therapy evaluation that includes history to rule out any adverse factors that will affect care; observes whether the patient's…	140	$50	$6.5K
97166	The occupational therapist (OT) performs an evaluation requiring clinical decision–making of moderate analytic complexity, which includes analysis of occupational profile, problem–focused assessment…	50	$50	$2.5K
97164	The provider, typically a physical therapist, conducts a physical therapy re–evaluation that includes history review and standardized tests and measures to assess body structure and function; she…	60	$30	$1.8K
92610	Code 92610 is in the Medicine/Special Otorhinolaryngologic Services Section. It involves special procedures of the ears/nose/throat. Diagnostic/treatment services not generally included in a…	30	$60	$1.7K
92523	A speech–language pathologist (SLP) evaluates the patient's speech sound production for issues such as incorrect pronunciation and patterns.	20	$60	$1.1K
97161	The provider, typically a physical therapist, conducts a physical therapy evaluation that includes history to rule out any adverse factors that will affect care; observes whether the patient's…	10	$50	$650

Medicaid: Competitive Analysis & Benchmarks

How this provider's Medicaid billing volume and revenue compare to other South Carolina providers billing the same CPT/HCPCS codes.

Claims Volume vs. South Carolina Distribution

Prisma Health-upstate — 3 of 10 codes billed far more than typical (above p95)

p5–p95 (all providers)p25–p75MedianThis providerOutlier

Rank Distribution — South Carolina

Full comparison — all codes billed, vs. South Carolina median

10 rows

CPT/HCPCS Code	Description	Rank	Provider Count	Median Claims	Avg Paid	Average Revenue
92507	The provider treats a patient with communication and hearing difficulties by directly interacting with the patient. He assesses the patient with impairment in his ability to make sounds, along with…	3	340	2,970	$80	$711.1K
97530	The provider uses various activities during direct contact with the patient to improve the patient’s functional performance. Use this code for each 15 minutes of activity.	4	350	2,590	$70	$550.2K
97110	Therapeutic exercise is a form of physical therapy that utilizes specially designed exercises and activities to help patients gain better mobility and fitness levels. Normally used on patients with…	12	290	2,600	$60	$414.4K
92526	The provider treats a swallowing disorder through medications, rehabilitation, or a feeding tube, to identify the cause of improper functioning.	21	40	390	$40	$65.5K
97161	The provider, typically a physical therapist, conducts a physical therapy evaluation that includes history to rule out any adverse factors that will affect care; observes whether the patient's…	79	90	170	$20	$25.3K
92610	Code 92610 is in the Medicine/Special Otorhinolaryngologic Services Section. It involves special procedures of the ears/nose/throat. Diagnostic/treatment services not generally included in a…	8	10	70	$40	$23.6K
92523	A speech–language pathologist (SLP) evaluates the patient's speech sound production for issues such as incorrect pronunciation and patterns.	50	70	30	$100	$20.7K
97162	The provider, typically a physical therapist, conducts a physical therapy evaluation that includes history to rule out any adverse factors that will affect care; observes whether the patient's…	28	60	110	$20	$13.3K
97166	The occupational therapist (OT) performs an evaluation requiring clinical decision–making of moderate analytic complexity, which includes analysis of occupational profile, problem–focused assessment…	17	30	70	$20	$8.1K
97164	The provider, typically a physical therapist, conducts a physical therapy re–evaluation that includes history review and standardized tests and measures to assess body structure and function; she…	12	20	60	$20	$3.3K

Provider	State	Taxonomy	Medicare Revenue	Medicaid Revenue
South Carolina Dept Of Mental Health Accounting Office	SC	Mental Health Clinic/Center (Including Community Mental Health Center)	$0	$61.9M
St Francis Hospital Inc	SC	General Acute Care Hospital	$0	$17.8M
South Carolina Dept Of Mental Health Accounting Office	SC	Mental Health Clinic/Center (Including Community Mental Health Center)	$0	$13.8M
County Of Greenville	SC	Land Ambulance	$4.2M	$9.2M
Greenville Proaxis Therapy, LLC	SC	Physical Therapist	$0	$7.9M
Carolina Family Services, Inc.	SC	Community/Behavioral Health Agency	$0	$5.5M
Ahead Start LLC	SC	Early Intervention Provider Agency	$0	$4.5M
Greenville Health System	SC	Medically Fragile Infants and Children Day Care	$0	$4.2M
Vituity-south Carolina LLC	SC	Emergency Medicine Physician	$0	$4.1M
Corporate Care, LLC	SC	Home Health Agency	$0	$4.1M

Prisma Health-upstate — Billing Profile & Reimbursement Data

Sign up for Prisma Health-upstate — Billing Profile & Reimbursement Data policy alerts

Prisma Health-upstate — Billing Profile & Reimbursement Data

Sign up for Prisma Health-upstate — Billing Profile & Reimbursement Data policy alerts

Key Findings

Medicaid: Total Revenue Breakdown by CPT/HCPCS Code

Medicaid: Complete Services Breakdown

Medicaid: Competitive Analysis & Benchmarks

Related Providers

Nearby Providers

Frequently Asked Questions

References

Provider	State	Taxonomy	Medicare Revenue	Medicaid Revenue
Prisma Health University Medical Group	SC	Family Medicine Physician	$0	$171.7M
Prisma Health-upstate	SC	General Acute Care Hospital	$0	$86.9M
Prisma Health Medical Group-midlands	SC	Multi-Specialty Clinic/Center	$0	$77.6M
Prisma Health-upstate	SC	General Acute Care Hospital	$0	$25M
Prisma Health-upstate	SC	General Acute Care Hospital	$0	$22M
Prisma Health-upstate	SC	General Acute Care Hospital	$0	$15.6M
Prisma Health-upstate	SC	General Acute Care Hospital	$0	$13.1M
Prisma Health-upstate	SC	General Acute Care Hospital	$0	$10.9M
Prisma Health-upstate	SC	General Acute Care Hospital	$0	$10.7M
Prisma Health-upstate	SC	General Acute Care Hospital	$0	$9.3M