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 Dakota for Medicaid) — rank 1 means the highest claims volume for that code.

Why is the Medicaid comparison limited to South Dakota 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 Dakota (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.

Avera St Marys (NPI 1720326713)

Key Findings

Field	Value
Entity Type	Organization
Organization	Avera St Marys
Address	801 E Sioux Ave
City	Pierre
State	SD
ZIP	57501
Taxonomy	Multi-Specialty Clinic/Center
NPI Enumerated	January 25, 2013

Payer Source	Total Paid
Medicaid	$4.6M
Medicare	$0

This provider is effectively single‑payer in the available claims data: there is no Medicare billing on file and lifetime Medicaid revenue is $4.6M. The NPI was enumerated 2013-01-25 (~13 years ago), indicating an established practice footprint in Pierre, SD but with activity concentrated in the Medicaid program rather than Medicare.

Revenue concentration is high: the top three Medicaid codes account for 53.7% of the provider's total Medicaid revenue. Those top lines are 99213 ($1.2M, 29.3% of Medicaid revenue), 99214 ($731.7K, 18.4%), and 99391 ($235.1K, 5.9%), showing that a small set of E/M and preventive codes drive most Medicaid dollars.

The code mix points to a primary care–focused outpatient clinic with substantial preventive and pediatric activity: high volumes of 99213 and 99214 indicate routine established patient visits and chronic care management, while 99391 and 99392 reflect periodic preventive medicine visits. High counts for 90460 (5.1K claims, $173.2K revenue) further reinforce a robust vaccination and well‑child service line.

99213 is a clear statewide volume outlier for this provider: it ranks #8 of 344 providers in‑state (98th percentile) and is described as notably above typical state volume, signaling market leadership in established outpatient visits. By contrast, 99214 ranks #12 of 260 (96th percentile) but is labeled a typical, unremarkable volume, suggesting the provider’s strength is driven more by high throughput of lower‑intensity E/M visits than by a disproportionate share of higher‑complexity office visits.

Beyond primary care, the claim mix shows meaningful obstetrics, imaging and inpatient/observation activity consistent with a multi‑specialty clinic offering on‑site or closely affiliated services: notable lines include 76816 ($88.4K), 76801 ($42K), 74177 ($101.6K), 70450 ($42.3K), and hospital discharge E/M codes such as 99238 ($92.6K) and 99239 ($58.4K). These entries imply either in‑house capacity or regular referral pathways for prenatal ultrasound, CT imaging and inpatient management.

Several codes indicate the practice balances high encounter volume with many low‑value/unit services: W0037 has 6.6K claims for $98.3K (2.5% of Medicaid revenue) and 71046 shows 4K claims for $39.7K (1.0%). The presence of high‑count, low‑paid codes alongside higher‑revenue E/M lines suggests operational throughput and frequent short encounters are a key part of the revenue model.

The provider shows usage of newer or specialized testing codes that contribute materially to revenue: 0241U accounts for $119.4K (3.0% of Medicaid revenue) and ranks #5 of 35 in‑state (88th percentile). While the description for 0241U is not provided, its placement in the top 25 indicates adoption of specialized services or diagnostics that supplement core primary care revenues.

From a contracting and competitive standpoint, AVERA ST MARYS appears to be an important Medicaid outpatient provider in South Dakota: long tenure (~13 years), $4.6M in Medicaid lifetime revenue, and top‑ranked volume on key outpatient E/M codes (notably 99213) position it as a significant statewide player for routine primary care and preventive services, but absence of Medicare billing means its role in Medicare networks cannot be assessed from these data.

Medicaid: Complete Services Breakdown

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

141 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…	32,290	$40	$1.2M
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…	13,550	$50	$731.7K
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…	3,850	$60	$235.1K
99203	The provider sees a new 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 provider…	3,630	$50	$196K
90460	In this procedure, the provider administers a single live attenuated vaccine through a parenteral, oral, intranasal, intramuscular, or intravenous to a patient up to 18 years of age.	5,100	$30	$173.2K
99392	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…	2,660	$60	$162.4K
0241U	N/A	1,050	$110	$119.4K
74177	The provider performs computed tomography of the abdomen and pelvis with contrast material to diagnose the cause of abdominal or pelvic pain or other abnormalities of the internal organs.	1,450	$70	$101.6K
W0037	N/A	6,550	$20	$98.3K
99238	The provider sees a patient for hospital inpatient or observation discharge day management, involving evaluation and management (E/M). The provider spends 30 minutes or less on the service on the…	1,930	$50	$92.6K

Showing 1–10 of 141

Medicaid: Competitive Analysis & Benchmarks

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

Claims Volume vs. South Dakota Distribution

Avera St Marys — 3 of 25 codes billed far more than typical (above p95)

p5–p95 (all providers)p25–p75MedianThis providerOutlier

Rank Distribution — South Dakota

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

141 rows

CPT/HCPCS Code	Description	Rank	Provider Count	Median Claims	Avg Paid	Average Revenue
59400	In this global service, the provider and nonphysician healthcare providers in the practice provide all of the antepartum care, admission to the hospital for delivery, labor management, including…	6	10	30	$1,280	$579.7K
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…	8	340	1,010	$100	$511K
76811	The provider performs an ultrasound study using a transabdominal approach to examine the fetus and mother, along with additional examination of the fetal anatomy, such as the heart rate, amniotic…	5	10	2,020	$100	$303.8K
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…	12	260	860	$80	$222.6K
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…	6	40	1,100	$80	$181.3K
99232	The provider sees a patient for a subsequent hospital inpatient or observation care visit involving evaluation and management (E/M). The visit involves a moderate level of medical decision making or…	18	70	400	$40	$172.5K
76819	The provider performs a biophysical profile test to measure the health of the baby during pregnancy using only ultrasound and not a nonstress test.	4	10	670	$40	$165.4K
99233	The provider sees a patient for a subsequent hospital inpatient or observation care visit involving evaluation and management (E/M). The visit involves a high level of medical decision making or the…	20	40	250	$50	$151.7K
74177	The provider performs computed tomography of the abdomen and pelvis with contrast material to diagnose the cause of abdominal or pelvic pain or other abnormalities of the internal organs.	6	20	100	$70	$140K
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	30	270	$70	$138.6K

Showing 1–10 of 141

Provider	State	Taxonomy	Medicare Revenue	Medicaid Revenue
Sanford Medical Center Fargo	ND	Family Medicine Physician	$0	$75.9M
Sanford Medical Center	SD	Family Medicine Physician	$0	$68.8M
The Duluth Clinic, Ltd	MN	Multi-Specialty Clinic/Center	$0	$51.7M
Innovis Health, LLC	ND	General Acute Care Hospital	$0	$25.5M
St. Marys Regional Health Center	MN	Rural Acute Care Hospital	$0	$18.7M
Essentia Health Virginia, LLC	MN	General Acute Care Hospital	$0	$12.9M
Avera Mckennan	SD	Family Medicine Physician	$0	$10.6M
Avera Mckennan	SD	Psychiatry Physician	$0	$9.1M
Avera Mckennan	SD	Home Infusion Agency	$0	$6.7M
Avera Mckennan	SD	Air Ambulance	$0	$5.3M

Provider	State	Taxonomy	Medicare Revenue	Medicaid Revenue
Homecare Services Of South Dakota, Inc.	SD	Home Health Agency	$0	$20.1M
Resources For Human Development	SD	Case Management Agency	$0	$8.5M
Capital Area Counseling Service, Inc	SD	Clinical Social Worker	$0	$7.6M
Oahe, Inc.	SD	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	$0	$4.4M
Rising Hope Counseling, LLC	SD	Mental Health Counselor	$0	$4M
Central Dakota Eyecare, LLP	SD	Optometrist	$0	$1.8M
Avera St Marys	SD	General Acute Care Hospital	$0	$1.7M
Delta Dental Of South Dakota Foundation	SD	Dental Clinic/Center	$0	$1.2M
Delta Dental Of South Dakota Foundation	SD	Dental Clinic/Center	$0	$1M
Delta Dental Of South Dakota Foundation	SD	Dental Clinic/Center	$0	$594K

Avera St Marys — 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