Annual Wellness Visit; Includes A Personalized Prevention Plan Of Service (pps), Initial Visit in New York

New York Pricing in Context

In New York, CPT code G0438 (Annual Wellness Visit; Includes A Personalized Prevention Plan Of Service (pps), Initial Visit) carries an average Medicare payment of $170.06 — 13% above the national benchmark of $150.68. 6.2K providers across the state submitted claims for this procedure in 2023, performing 49.5K total services. Individual payments in NY 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 New York is $476.08, 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 New York 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 Preventive Screening procedures, the estimated commercial insurance price in New York lands near $425.16, with self-pay cash prices typically around $258.47. 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.