Loading...
NPI 1841293826 · Salisbury, MD · Ophthalmology Physician
Customize your policy alerts
Get alerted when relevant policies change without checking for updates manually.
Monitor payer policy activity
James Rial is a ophthalmology physician provider located in Salisbury, Maryland. This profile covers 19 Medicare and 1 Medicaid CPT/HCPCS procedure codes, with claims volume, average reimbursement, and total revenue by code, benchmarked against other providers billing the same services.
Provider details (source: NPPES NPI Registry)
| Field | Value |
|---|---|
| Entity Type | Individual |
| Organization | James Rial |
| Address | 31455 Winterplace Pkwy |
| City | Salisbury |
| State | MD |
| ZIP | 21804 |
| Taxonomy | Ophthalmology Physician |
| NPI Enumerated | May 24, 2005 |
Lifetime revenue by payer source (source: CMS Medicare & Medicaid claims data)
| Payer Source | Total Paid |
|---|---|
| Medicare | $4.7M |
| Medicaid | $510 |
This provider’s billing footprint is overwhelmingly Medicare‑driven: Total Medicare revenue is $4.7M versus Total Medicaid revenue of $508, so Medicaid is effectively negligible to the provider’s revenue base. In practical terms the practice operates as a Medicare-centric ophthalmology provider rather than a mixed‑payer clinic.
Revenue concentration on Medicare is very high: the precomputed top 3 Medicare codes by revenue account for 81.9% of the provider’s Medicare revenue. The top three codes are J0178 ($2M, 42.1%), J2777 ($1.5M, 32.5%), and 99214 ($336K, 7.3%), indicating a small number of services drive the bulk of Medicare dollars.
Clinical/service‑line profile points to a retina/injection‑focused ophthalmology practice. High revenue and claim volume for intravitreal injection codes (J0178: 2.8K claims, $686 avg paid/claim, $2M revenue; J2777: 53.8K claims, $28 avg paid/claim, $1.5M revenue; 67028: 2.5K claims, $221.7K revenue) together with retina imaging codes (92134: 4.5K claims, $139.7K revenue; 92250: 936 claims, $26.2K revenue) show the operation centers on injection therapy and retinal diagnostics.
The provider is a strong national performer on several high‑impact codes. J0178 ranks #208 of 3204 providers nationally (94th percentile; notably above typical national volume) and J2777 ranks #91 of 2039 (96th percentile; notably above typical national volume), while 99214 ranks #107 of 479517 (100th percentile; extreme outlier, far above typical national volume). This profile signals a major contributor to Medicare activity for anti‑VEGF and related services.
Several codes are statistical outliers or unusually concentrated in volume and E&M capture. 99214 and 92134 are both flagged as 100th percentile / extreme outlier (far above typical national volume), which indicates unusually high throughput of moderately complex established‑patient visits and retinal OCT imaging relative to national peers. These characteristics suggest operational workflows that generate large counts of both injections and the associated evaluation and management encounters.
Medicaid activity is minimal and highly concentrated: the precomputed top 3 Medicaid codes account for 100.0% of Medicaid revenue and that total Medicaid revenue is only $508. All Medicaid billing is for 92134 (12 claims, $42 avg paid/claim, $504 revenue), where the provider ranks #79 of 81 in‑state (0th percentile; typical, unremarkable volume), indicating virtually no Medicaid market presence in Maryland.
The combination of high injection volumes and significant imaging and E&M billing implies that changes in utilization management or drug coverage for intravitreal therapies would materially affect this provider’s Medicare revenue. Given that J0178 and J2777 together represent a large share of Medicare dollars, payer policy, prior authorization requirements, or formulary shifts for these codes would disproportionately change spend tied to this NPI.
The provider is long‑tenured with an NPI enumeration date of 2005-05-24 (~21 years ago), consistent with an established practice that has developed a specialized service mix over time. Longevity combined with concentrated, high‑volume Medicare billing patterns supports classifying this entity as an experienced, retina‑focused ophthalmologist with a sustained Medicare patient base.
Medicare revenue breakdown by CPT/HCPCS procedure code.
View: Bar Chart1 / 2
The CPT/HCPCS codes generating the most Medicare revenue for this provider.
19 rows
| CPT/HCPCS Code | Description | Claims | Avg Paid | Revenue |
|---|---|---|---|---|
| J0178 | Injection, aflibercept, 1 mg | 2,850 | $690 | $2M |
| J2777 | Injection, faricimab‑svoa, 0.1 mg | 53,820 | $30 | $1.5M |
| 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… | 3,690 | $90 | $336K |
| 67028 | The provider injects a medication into the vitreous chamber of the eye as an isolated procedure or a separate procedure unrelated to any other procedure being performed on the eye. | 2,460 | $90 | $221.7K |
| 92134 | The provider performs computerized diagnostic imaging of the retina in the posterior segment (back part) of the eye, interprets the data, and provides a report. The service may be on one or both eyes. | 4,510 | $30 | $139.7K |
| J2778 | Injection, ranibizumab, 0.1 mg | 680 | $180 | $123.6K |
| 92014 | An ophthalmologist sees an established patient for a comprehensive level eye examination. Generally, a patient is considered to be "established" if the same physician, or any physician in the group… | 840 | $80 | $70.6K |
| 67210 | The provider destroys a lesion of the retina using a laser beam that heats up the tissue. | 120 | $420 | $51K |
| 99204 | The provider sees a new 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 provider… | 320 | $120 | $38.7K |
| J2781 | Injection, pegcetacoplan, intravitreal, 1 mg | 290 | $120 | $34.2K |
Showing 1–10 of 19
How this provider's Medicare billing volume and revenue compare to other providers nationally and within its state, across 19 CPT/HCPCS codes.
View: State1 / 2
Full comparison — all codes billed, vs. state median
19 rows
| CPT/HCPCS Code | Rank | Provider Count | Median Claims | Avg Paid | Average Revenue |
|---|---|---|---|---|---|
| J0178 | 14 | 100 | 950 | $690 | $887.3K |
| J2777 | 6 | 70 | 8,520 | $30 | $487.3K |
| J2781 | 15 | 20 | 620 | $120 | $258.6K |
| J2778 | 25 | 50 | 650 | $180 | $207.8K |
| 67028 | 6 | 120 | 700 | $100 | $101.5K |
| 92014 | 110 | 620 | 210 | $90 | $44K |
| 67113 | 4 | 10 | 20 | $1,170 | $31.7K |
| 67042 | 5 | 30 | 20 | $1,060 | $25.4K |
| 99214 | 5 | 10,270 | 150 | $90 | $24.1K |
| 67210 | 3 | 20 | 30 | $430 | $21K |
Showing 1–10 of 19
Medicaid revenue breakdown by year and by CPT/HCPCS procedure code, including monthly billing trends and the top codes driving revenue.
View: By Year1 / 3
Every CPT/HCPCS code this provider has billed to Medicaid, with claims volume, average payment, and total revenue.
1 rows
| CPT/HCPCS Code | Description | Claims | Avg Paid | Revenue |
|---|---|---|---|---|
| 92134 | The provider performs computerized diagnostic imaging of the retina in the posterior segment (back part) of the eye, interprets the data, and provides a report. The service may be on one or both eyes. | 10 | $40 | $500 |
How this provider's Medicaid billing volume and revenue compare to other Maryland providers billing the same CPT/HCPCS codes.
Full comparison — all codes billed, vs. Maryland median
1 rows
| CPT/HCPCS Code | Description | Rank | Provider Count | Median Claims | Avg Paid | Average Revenue |
|---|---|---|---|---|---|---|
| 92134 | The provider performs computerized diagnostic imaging of the retina in the posterior segment (back part) of the eye, interprets the data, and provides a report. The service may be on one or both eyes. | 79 | 80 | 220 | $30 | $82K |
Other providers in the same ZIP code as James Rial, ranked by combined Medicare and Medicaid revenue.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.