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 1437605532)

Key Findings

Field	Value
Entity Type	Organization
Organization	Prisma Health-upstate
Address	20 Medical Ridge Dr
City	Greenville
State	SC
ZIP	29605
Taxonomy	General Acute Care Hospital
NPI Enumerated	August 29, 2016

Payer Source	Total Paid
Medicaid	$25M
Medicare	$0

This provider is effectively single-payer at the Medicare/Medicaid level: there is no Medicare billing on file while Medicaid revenue is reported at $25M, so Medicaid dominates the revenue footprint for the dataset available. The NPI was enumerated on 2016-08-29 (~10 years ago), indicating roughly a decade of activity under the current enumeration.

Revenue is concentrated in a small set of outpatient-focused codes: the top three Medicaid codes (99213, 99212, 94760) together account for 37.4% of the provider’s total Medicaid revenue, with those individual code revenues reported as $3.7M (99213), $2.8M (99212), and $2.4M (94760). This concentration shows a heavy reliance on high-volume evaluation-and-management and point-of-care respiratory monitoring services for Medicaid revenue.

The code mix points to a hospital outpatient/ambulatory clinic and pediatric preventive services focus: high counts and revenues for E/M codes (99213, 99212, 99214, 99215) alongside pediatric well-visit codes (99391, 99392, 99393, 99394) and specimen/lab codes (36415, 83655, 0202U, C9803) suggest the General Acute Care Hospital is operating a substantial outpatient clinic and on-site lab/testing capability. The presence of infusion/injection codes and (combined revenue of ~$2.6M) also indicates outpatient infusion or therapy services are material to the Medicaid business line.

Several Medicaid codes show dominant in-state volume and high percentile rankings, signaling a strong competitive position in these service lines. Examples include 99212 (ranks #3 of 607, 100th percentile; notably above typical state volume), 94760 (ranks #1 of 139, 100th percentile; extreme outlier), and 99213 (ranks #38 of 2766, 99th percentile; notably above typical state volume), which together indicate the provider is a major statewide player for routine outpatient visits and pulse-ox monitoring.

A number of specific codes are statistical outliers or notably above typical state volume for their categories, highlighting areas of exceptional throughput: 94760 is labeled an "extreme outlier" and ranks #1, 99393 is an "extreme outlier" (ranks #7 of 389, 98th percentile), and 83655 is also flagged as an "extreme outlier" (ranks #5 of 127, 97th percentile). These outlier signals point to unusually high volumes of pulse oximetry, pediatric well visits, and lead testing relative to in-state peers.

High-value per-claim services contribute meaningfully despite lower claim counts: 96365 has an average paid/claim of $1094 and $1M revenue, and 96372 has an average paid/claim of $870 and $1.6M revenue. That pattern implies that infusion and injectable therapies are important revenue drivers alongside the high-volume E/M and testing services.

Claim volumes are sizeable across several outpatient codes, indicating a high-throughput ambulatory operation: for Medicaid the provider reported 48.9K claims for 99213, 31.5K for 99212, and 27.1K for 94760. Those claim volumes, together with the hospital taxonomy, support an operational profile of a general acute care hospital with heavy outpatient clinic traffic and routine in-clinic diagnostics/testing.

The combined picture—no Medicare billing on file, $25M in Medicaid revenue, top-three-code concentration of 37.4%, and multiple top-100 and top-1 state rankings—suggests strategic vulnerability to Medicaid policy or rate changes but also clear market strength in Medicaid outpatient and pediatric services within South Carolina. Analysts should interpret this provider as a Medicaid-centric, high-volume outpatient provider with specialized capacity in respiratory monitoring, pediatric preventive care, lab testing, and outpatient infusion services.

Medicaid: Complete Services Breakdown

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

127 rows

CPT/HCPCS Code	Description	Claims	Avg Paid	Revenue
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…	48,880	$80	$3.7M
99212	The provider sees an established patient for an office visit or other outpatient visit involving evaluation and management. The visit involves a straightforward level of medical decision making,…	31,460	$90	$2.8M
94760	The provider takes a single measurement of the patient’s oxygen saturation using a sensor on the ear or finger.	27,120	$90	$2.4M
36415	In this procedure, the provider inserts a needle into a vein to collect a blood sample.	14,150	$150	$2.2M
99391	Preventive medicine services are provided to individuals who are not in need of any immediate medical attention, but need to undergo a periodic health checkup as a preventive measure. Well–baby…	20,810	$90	$1.9M
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…	1,780	$870	$1.6M
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…	22,180	$50	$1.1M
C9803	Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source	6,300	$170	$1M
96365	The provider administers the initial intravenous infusion of a medication or other substance for a period up to one hour to prevent, treat, or diagnose a condition or disease.	930	$1,090	$1M
99393	The provider performs an established well–patient visit for a child who is between the ages of 5 and 11.	13,100	$60	$838.2K

Showing 1–10 of 127

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 — 12 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

127 rows

CPT/HCPCS Code	Description	Rank	Provider Count	Median Claims	Avg Paid	Average Revenue
J1745	Injection, infliximab, excludes biosimilar, 10 mg	6	10	810	$1,040	$1.7M
90378	Immunoglobulin is a very complex protein that is produced by certain cells in the body to protect it from various types of infections and produce passive immunity. RSV–IgIM (respiratory syncytial…	3	10	340	$1,490	$1.1M
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.	80	210	1,470	$60	$615K
87636	The lab analyst performs the technical steps to detect and differentiate severe acute respiratory syndrome coronavirus 2 (SARS–CoV–2), influenza A, and influenza B using a multiplex amplified nucleic…	38	70	600	$130	$307.2K
99391	Preventive medicine services are provided to individuals who are not in need of any immediate medical attention, but need to undergo a periodic health checkup as a preventive measure. Well–baby…	11	280	600	$90	$299K
C9803	Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source	8	50	510	$110	$290.3K
96413	Chemotherapy is a therapeutic procedure used for the treatment of cancer via the use of chemical agents. These chemical agents (drugs) work on the cancerous cells of the body to destroy them. These…	39	50	520	$110	$277.4K
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…	15	90	730	$60	$275.7K
87637	The lab analyst performs the technical steps to detect and differentiate severe acute respiratory syndrome coronavirus 2 (SARS–CoV–2), influenza A, influenza B, and respiratory syncytial virus (RSV)…	45	60	540	$110	$271.5K
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…	38	2,770	210	$60	$254.5K

Showing 1–10 of 127

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

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	$22M
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

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