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.

Pine Ridge Indian Health Service Hospital (NPI 1962559518)

Key Findings

Field	Value
Entity Type	Organization
Organization	Pine Ridge Indian Health Service Hospital
Address	210 1st St
City	Wanblee
State	SD
ZIP	57577
Taxonomy	Clinic/Center
NPI Enumerated	January 5, 2007

Payer Source	Total Paid
Medicaid	$4.6M
Medicare	$0

This provider has no Medicare billing on file and reports $4.6M in lifetime Medicaid revenue, making it effectively single-payer in the public payer data available. That concentration on Medicaid creates revenue dependence on state programs rather than on Medicare patient flows or fee schedules.

Revenue is highly concentrated in office-based evaluation-and-management services: the top three Medicaid codes (99213, 99214, 99212) account for 76.9% of this provider’s total Medicaid revenue, with 99213 generating $2M (43.3%), 99214 $1.1M (23.5%), and 99212 $457.5K (10.0%). These three codes are established-patient E&M visits, indicating the organization’s core operation is ambulatory primary care and routine follow-up visits.

The presence of vaccine administration and low-complexity visit codes supports a preventive and general outpatient care model: 90471 (vaccine administration) produced $188.3K (4.1%) and 99211 accounted for $168.7K (3.7%). Together these codes imply regular immunization and brief office-visit throughput that complements the higher-volume E&M activity.

Home-based services appear to be a notable element of the mix: 99600 (home visit) generated $152.2K (3.3%) and ranks #1 of 4 providers in-state (100th percentile; typical, unremarkable volume for this code). Being top-ranked among a very small in-state peer set suggests a relative local specialization in home visits, even though the absolute share of overall revenue is modest.

Competitive standing across core E&M codes is broadly in the middle-to-upper range of state peers: 99213 ranks #79 of 344 providers in-state (77th percentile; typical, unremarkable volume for this code), 99214 ranks #70 of 260 (73th percentile; typical, unremarkable volume for this code), and 99212 ranks #36 of 155 (77th percentile; typical, unremarkable volume for this code). These ranks indicate the provider is a steady, typical participant statewide for ambulatory visits rather than a dominant high-volume hub.

The claims mix includes a high-count, low-dollar line item W0037 (4.1K claims, $109.5K, 2.4%) that ranks #30 of 164 providers in-state (82th percentile; typical, unremarkable volume for this code), which points to high-frequency, lower-paid services or supplies in support of clinical operations. The file also shows other procedure/administration codes with moderate payments (0071A, 0072A, 0002A, 0001A, 0052A) that collectively reflect supplemental revenue streams tied to episodic procedures or immunizations.

The provider reports COVID-19 molecular testing activity via 87635 ($51.9K, 1.1%) and appears to offer some ancillary diagnostic capacity (87635 ranks #25 of 37 providers in-state (33th percentile; typical, unremarkable volume for this code)). While testing is a smaller share of revenue, its presence signals on-site or affiliated lab/testing services that support clinical care continuity.

The NPI was enumerated on 2007-01-05 (~19 years ago), indicating long-standing enrollment in payer systems. This tenure supports interpretation of the observed billing mix as established patterns rather than transient start-up activity.

Medicaid: Competitive Analysis & Benchmarks

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…	4,360	$460	$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…	2,310	$470	$1.1M
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,…	1,060	$430	$457.5K
90471	In this procedure, the provider administers a live attenuated vaccine using a percutaneous, intradermal, subcutaneous, or intramuscular route.	340	$560	$188.3K
99211	An established patient presents for an office or other outpatient visit that may not require the presence of a physician or other qualified healthcare professional.	330	$510	$168.7K
99600	Use 99600 to report a home visit service or procedure that does not have a specific code.	440	$350	$152.2K
W0037	N/A	4,060	$30	$109.5K
0071A	N/A	140	$540	$76.4K
0072A	N/A	130	$600	$75.9K
0002A	N/A	140	$500	$70.4K

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

Pine Ridge Indian Health Service Hospital — 1 of 20 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

23 rows

CPT/HCPCS Code	Description	Rank	Provider Count	Median Claims	Avg Paid	Average 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…	79	340	1,010	$100	$511K
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…	70	260	860	$80	$222.6K
99211	An established patient presents for an office or other outpatient visit that may not require the presence of a physician or other qualified healthcare professional.	21	60	120	$210	$171.2K
G0463	Hospital outpatient clinic visit for assessment and management of a patient	44	50	1,650	$10	$125.4K
99215	The provider sees an established patient for an office visit or other outpatient visit involving evaluation and management. The visit involves a high level of medical decision making, and/or the…	49	70	130	$100	$99K
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,…	36	160	210	$120	$97.4K
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…	123	130	390	$90	$86.6K
D0140	Limited oral evaluation – problem focused	35	60	120	$140	$84.7K
0002A	N/A	11	30	90	$260	$82.8K
0001A	N/A	9	40	70	$240	$74.5K

Showing 1–10 of 23

Pine Ridge Indian Health Service Hospital — Billing Profile & Reimbursement Data

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Pine Ridge Indian Health Service Hospital — 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

Frequently Asked Questions

References