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 1407301211)

Field	Value
Entity Type	Organization
Organization	Prisma Health-upstate
Address	1120 Grove Rd
City	Greenville
State	SC
ZIP	29605
Taxonomy	General Acute Care Hospital
NPI Enumerated	August 22, 2016

Payer Source	Total Paid
Medicaid	$22M
Medicare	$0

Key Findings

PRISMA HEALTH-UPSTATE shows an effectively single-payer footprint in the available data: there is no Medicare billing on file and lifetime Medicaid revenue is reported as $22M. This concentration means analyses of utilization and competitive position should be interpreted through a Medicaid-only lens rather than a mixed Medicare/Medicaid model.

Revenue is highly concentrated in a small set of lab and diagnostics codes: the precomputed top three Medicaid codes account for 60.1% of the provider's total Medicaid revenue. Those top drivers are 36415 ($8.2M, 37.6%), 81025 ($2.6M, 11.8%), and 81003 ($2.4M, 10.8%), indicating that a majority of Medicaid dollars flow from specimen collection and urine testing services.

The code mix points to a lab- and outpatient-clinic–centric operation. 36415 (blood collection) is the largest single Medicaid revenue line, and 81025 and 81003 (pregnancy test and automated dipstick urinalysis) are the second and third drivers, suggesting heavy throughput for specimen collection and high-volume point-of-care or reference lab testing. Additional high-volume lab codes such as 87491 (Chlamydia NAAT), 87210 (wet mount), and 87086 (urine culture colony count) reinforce a laboratory-focused service line.

PRISMA is a dominant statewide performer on several discrete services despite modest overall Medicaid revenue: 81003 ranks #1 of 495 providers in-state (100th percentile) and is labeled an "extreme outlier, far above typical state volume," while 36415 ranks #14 of 713 (98th percentile) and 87210 ranks #2 of 120 (99th percentile). Those ranks indicate the provider is a major volume hub for specific lab procedures in South Carolina even if total Medicaid revenue is $22M.

Ambulatory evaluation-and-management activity is also substantive and high-volume: 99213 shows 59.8K claims and $2M revenue (9.3%), ranking #30 of 2766 providers in-state (99th percentile, extreme outlier), and 99214 has 43.5K claims and $478.9K revenue (2.2%), ranking #23 of 2483 (99th percentile). These volumes suggest robust outpatient clinic throughput co-located with the laboratory services rather than a purely inpatient acute-care billing profile.

The provider reports meaningful use of therapeutic and preventive outpatient procedures: 96372 (therapeutic/prophylactic injections) accounts for $1M (4.6%) with 9.5K claims, and contraceptive device codes 58301 and 58300 both rank #1 within small state cohorts, indicating specialized reproductive health procedure activity alongside routine lab services. These procedure-level ranks signal service-line breadth within ambulatory care.

Payment and coding intensity are heterogeneous: high average paid/claim lines include 81025 at $332/claim and 36415 at $188/claim, while some extremely high-volume codes carry low per-claim payments (for example 99214 averages $11/claim). This pattern — high-volume, lower-paid E/M and specific high-paid lab procedures — is consistent with a throughput-driven outpatient and laboratory business model that relies on volume to generate Medicaid revenue.

The provider's NPI was enumerated on 2016-08-22 (noted as ~10 years ago), establishing at least a multi-year presence in state Medicaid billing. Given the pointed high-percentile ranks on multiple lab and ambulatory codes, the entity appears established and specialized in outpatient specimen collection, diagnostic testing, and associated clinic visits within South Carolina's Medicaid market.

Medicaid: Complete Services Breakdown

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

102 rows

CPT/HCPCS Code	Description	Claims	Avg Paid	Revenue
36415	In this procedure, the provider inserts a needle into a vein to collect a blood sample.	43,810	$190	$8.2M
81025	The lab analyst performs the pregnancy test on a urine specimen using a methodology or kit that the analyst can read visually for a direct readout.	7,760	$330	$2.6M
81003	The lab analyst inserts a dip stick into a freshly collected urine specimen, removes the dipstick, and shakes off the excess urine. She places the stick onto a mechanical dip stick reader that will…	64,020	$40	$2.4M
99213	The provider sees an established patient for an office visit or other outpatient visit involving evaluation and management. The visit involves a low level of medical decision making, and/or the…	59,800	$30	$2M
87491	The lab analyst performs a test for Chlamydia trachomatis using amplified nucleic acid probe technique.	18,760	$80	$1.5M
96372	A therapeutic, prophylactic, or diagnostic substance (a fluid, a drug, etc.) is injected via intramuscular or subcutaneous route into the patient's body. The procedure is performed by the physician…	9,510	$110	$1M
87210	The lab analyst or microbiologist performs a wet mount preparation of a specimen, usually from material collected on a swab or placed directly on a microscope slide.	5,940	$100	$611.8K
87086	Culture, bacterial; quantitative, colony count, urine.	18,000	$30	$557.9K
87624	The lab analyst performs a test to determine the presence of human papillomavirus, or HPV. The provider uses nucleic acid detection for high–risk types and produces a pooled result.	5,050	$100	$479.9K
99214	The provider sees an established patient for an office visit or other outpatient visit involving evaluation and management. The visit involves a moderate level of medical decision making, and/or the…	43,530	$10	$478.9K

Showing 1–10 of 102

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 — 11 of 25 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

102 rows

CPT/HCPCS Code	Description	Rank	Provider Count	Median Claims	Avg Paid	Average Revenue
80053	The lab analyst performs a comprehensive metabolic panel, or CMP test in which he measures the blood level of 14 chemicals the code descriptor lists for the panel.	70	210	1,470	$60	$615K
C9803	Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source	40	50	510	$110	$290.3K
U0003	Infectious agent detection by nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, making use of high…	72	90	730	$60	$275.7K
99213	The provider sees an established patient for an office visit or other outpatient visit involving evaluation and management. The visit involves a low level of medical decision making, and/or the…	30	2,770	210	$60	$254.5K
36415	In this procedure, the provider inserts a needle into a vein to collect a blood sample.	14	710	350	$60	$247.2K
99214	The provider sees an established patient for an office visit or other outpatient visit involving evaluation and management. The visit involves a moderate level of medical decision making, and/or the…	23	2,480	350	$80	$246K
87798	The lab analyst performs a test for an infectious agent not specified in another code using an amplified nucleic acid probe technique. Use this code if you know the laboratory technique is amplified…	35	50	170	$60	$206K
88305	The physician, typically a pathologist, performs a level IV examination of a surgical pathology specimen. The examination includes accessioning the specimen into the lab, which involves formally…	53	130	780	$60	$178.3K
87491	The lab analyst performs a test for Chlamydia trachomatis using amplified nucleic acid probe technique.	7	120	1,100	$30	$170.4K
G0463	Hospital outpatient clinic visit for assessment and management of a patient	55	70	320	$40	$159.1K

Showing 1–10 of 102

Related Providers

Other providers that share a Tax Identification Number (TIN) with Prisma Health-upstate, ranked by combined Medicare and Medicaid revenue.

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-upstate	SC	General Acute Care Hospital	$0	$25M
Prisma Health-upstate	SC	Developmental Disabilities Clinic/Center	$0	$19.7M
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
Greenville Health Corporation	SC	Durable Medical Equipment & Medical Supplies	$0	$8.9M

Nearby Providers

Other providers in the same ZIP code as Prisma Health-upstate, ranked by combined Medicare and Medicaid revenue.

Provider	State	Taxonomy	Medicare Revenue	Medicaid Revenue
Heavenly Care Services Inc.	SC	Nursing Care Agency	$0	$12.1M
Speechworks, Inc.	SC	Speech-Language Pathologist	$0	$10.5M
Plan Home Health Care	SC	Nursing Care Agency	$0	$8.9M
Prisma Health-upstate	SC	General Acute Care Hospital	$0	$8.3M
Prisma Health-upstate	SC	Land Ambulance	$4.5M	$3.7M
Prisma Health-upstate	SC	Infusion Therapy Clinic/Center	$0	$7.5M
Prisma Health University Medical Group	SC	Diagnostic Radiology Physician	$0	$7.5M
Carolina Family Services Of Greenville LLC	SC	Community/Behavioral Health Agency	$0	$6M
New Horizon Family Health Services, Inc.	SC	Federally Qualified Health Center (FQHC)	$0	$5.8M
Prisma Health-upstate	SC	General Acute Care Hospital	$0	$4.6M

Prisma Health-upstate — Billing Profile & Reimbursement Data

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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