Principal Care Management Services For A Single High-Risk Disease, First 30 Minutes Of Clinical Staff Time Directed By Health Care Professional, Per Calendar Month in Massachusetts

Massachusetts Pricing in Context

In Massachusetts, CPT code 99426 (Principal Care Management Services For A Single High-Risk Disease, First 30 Minutes Of Clinical Staff Time Directed By Health Care Professional, Per Calendar Month) carries an average Medicare payment of $46.71 — 0% above the national benchmark of $46.61. 11 providers across the state submitted claims for this procedure in 2023, performing 41 total services. Individual payments in MA ranged from N/A at the low end to N/A at the high end, reflecting differences in provider setting (office vs. facility), modifiers, and the specific geographic locality code applied within the state.

The average billed charge in Massachusetts is $140.88, which is the figure uninsured patients would most likely encounter before any negotiation or charity discount. Medicare, by statute, only reimburses the allowed amount — the balance between billed and paid is written off under provider participation agreements. Insured patients generally pay a negotiated rate that falls between these two figures; the exact amount depends on plan design, deductible status, and in-network participation. Because Massachusetts sits above the national Medicare average, commercial rates in the state may also run higher than the US median.

Using RAND 2024 commercial-to-Medicare ratios for Emergency procedures, the estimated commercial insurance price in Massachusetts lands near $166.42, with self-pay cash prices typically around $86.75. Before scheduling, patients can request a Good Faith Estimate under the No Surprises Act, compare cash rates from hospital Machine-Readable Files, and confirm whether the provider is in-network with their specific plan. This page presents CMS reference data for informational use; it does not constitute medical or financial advice.