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.

Sumter Pediatrics, P.A. (NPI 1871593749)

Key Findings

Field	Value
Entity Type	Organization
Organization	Sumter Pediatrics, P.A.
Address	237 Church St
City	Sumter
State	SC
ZIP	29150
Taxonomy	Pediatrics Physician
NPI Enumerated	July 21, 2005

Payer Source	Total Paid
Medicaid	$24.4M
Medicare	$0

SUMTER PEDIATRICS, P.A. is effectively a single-payer Medicaid practice: there is no Medicare billing on file while total Medicaid revenue is $24.4M, indicating the provider operates almost entirely in the Medicaid market rather than serving a Medicare population. This concentration in one payer should shape payer-contracting and utilization analyses.

Revenue concentration is high: the precomputed top-3 Medicaid codes account for 66.1% of the provider's Medicaid revenue, with 99213 ($10.7M, 44.2%), 99214 ($2.8M, 11.6%), and 90460 ($2.5M, 10.4%) listed as the top three drivers. This indicates that a majority of revenue is produced by routine office E/M visits and vaccine administration, making the practice sensitive to changes in E/M or immunization reimbursement.

The code mix clearly reflects a high-volume pediatric primary care model focused on established office visits and preventive services: 99213 (149.2K claims, $72 avg paid/claim, $10.7M) and 99214 (27.1K claims, $104 avg paid/claim, $2.8M) are the largest revenue contributors, while preventive visit codes 99391 ($2.2M) and 99392 ($2.0M) also contribute materially. Combined with sizable vaccine administration revenue (90460 $2.5M and 90461 $423.7K), this pattern is consistent with a clinic that emphasizes routine well-child care and immunization delivery.

Competitive standing in-state is pronounced for core pediatric services: 99213 ranks #7 of 2766 providers in-state (100th percentile; extreme outlier) and 90460 ranks #8 of 652 (99th percentile; extreme outlier), indicating the practice is a dominant provider of routine established-patient visits and vaccine administration relative to peers in South Carolina. 99214 also ranks highly at #41 of 2483 (98th percentile; notably above typical state volume), reinforcing that dominance across higher-complexity E/M for established patients.

Preventive medicine activity is a clear strength: 99391 ranks #9 of 284 providers (97th percentile; notably above typical state volume), 99392 ranks #11 of 377 (97th percentile; notably above typical state volume), and 99393 ranks #11 of 389 (97th percentile; notably above typical state volume). These rankings, together with the dollar volumes reported for those codes, indicate sustained, above-typical throughput of well-child visits across pediatric age groups.

Point-of-care testing and infectious-disease diagnostics are significant ancillary services for the practice: 87428 ($516.9K, rank #6 of 142, 96th percentile), 87804 ($267.4K, rank #33 of 536, 94th percentile), and 87635 ($166.5K, rank #26 of 174, 86th percentile) show notable volumes consistent with outpatient respiratory and COVID/flu testing workflows in a pediatric setting. This mix suggests the clinic provides on-site testing that complements its high ambulatory visit volumes.

Routine screening and basic laboratory services are performed at scale: 85018 shows 33.4K claims ($66.8K revenue) and ranks #2 of 449 providers in-state (100th percentile; extreme outlier), while hearing screening 92551 shows 21.6K claims ($43.1K revenue) and ranks #1 of 94 providers (100th percentile; extreme outlier). High claim counts for these low-dollar codes point to frequent point-of-care screening and basic labs incorporated into well-child workflows.

The provider has long operational tenure: the NPI was enumerated 2005-07-21 (~21 years ago), indicating an established presence in the market. Longevity combined with high Medicaid revenue and top-percentile rankings for core pediatric services suggests a stable, mature pediatric practice with a sustained Medicaid patient base and significant share in routine pediatric care within the state.

Medicaid: Complete Services Breakdown

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

66 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…	149,180	$70	$10.7M
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…	27,080	$100	$2.8M
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.	50,410	$50	$2.5M
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…	22,270	$100	$2.2M
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…	18,880	$110	$2M
99393	The provider performs an established well–patient visit for a child who is between the ages of 5 and 11.	9,940	$110	$1.1M
99394	The provider performs an established well–patient visit for an adolescent who is between the ages of 12 and 17.	5,250	$120	$629.9K
87428	The lab analyst performs an immunoassay to qualitatively or semiquantitatively evaluate the patient specimen for antigens of severe acute respiratory syndrome (SARS) coronavirus, such as SARS–CoV–2…	8,080	$60	$516.9K
90461	In this procedure, the provider administers an additional live attenuated vaccine either via a parenteral, oral, intranasal, intramuscular, or intravenous to a patient up to 18 years of age after the…	16,950	$30	$423.7K
87804	The analyst performs an immunoassay with direct optical, meaning visual, observation to detect influenza, also called flu, in a patient sample, typically a throat or nasal swab or nasal washings.	8,910	$30	$267.4K

Showing 1–10 of 66

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

Sumter Pediatrics, P.A. — 15 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

66 rows

CPT/HCPCS Code	Description	Rank	Provider Count	Median Claims	Avg Paid	Average Revenue
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…	9	280	600	$90	$299K
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…	7	2,770	210	$60	$254.5K
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…	41	2,480	350	$80	$246K
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…	11	380	160	$100	$226.8K
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…	85	410	330	$50	$152.6K
99393	The provider performs an established well–patient visit for a child who is between the ages of 5 and 11.	11	390	100	$100	$148.3K
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…	143	230	430	$40	$129.9K
87635	Using an amplified nucleic acid probe technique, the lab analyst performs the necessary steps to identify the nucleic acids from the severe acute respiratory syndrome coronavirus 2 (SARS–COV–2) virus…	26	170	500	$50	$128.5K
99394	The provider performs an established well–patient visit for an adolescent who is between the ages of 12 and 17.	15	340	110	$110	$107.9K
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,…	482	610	190	$50	$98.4K

Showing 1–10 of 66

Provider	State	Taxonomy	Medicare Revenue	Medicaid Revenue
Prisma Health-midlands	SC	General Acute Care Hospital	$0	$28.1M
Tandem Health Sc	SC	Federally Qualified Health Center (FQHC)	$0	$17.3M
Colonial Family Practice, LLC	SC	Family Medicine Physician	$0	$9.5M
Tandem Health Sc	SC	Federally Qualified Health Center (FQHC)	$0	$7.8M
Prisma Health Tuomey	SC	Emergency Medicine Physician	$0	$6.8M
Wesmark Dental Health Center	SC	General Practice Dentistry	$0	$6.3M
Addus Healthcare (south Carolina), Inc.	SC	In Home Supportive Care Agency	$0	$5.5M
Carolina Children's Dentistry, LLC	SC	Pediatric Dentistry	$0	$5.2M
Sumter School District	SC	Local Education Agency (LEA)	$0	$4.2M
Kool Smiles, PC	SC	General Practice Dentistry	$0	$4.2M

Sumter Pediatrics, P.A. — Billing Profile & Reimbursement Data

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Sumter Pediatrics, P.A. — 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

Nearby Providers

Frequently Asked Questions

References