Add-on Rates for Providers Predominantly Delivering Family Planning Services

Procedure Code 

Description 

Amount of Add-On Rate, rounded to nearest dollar

11976 

Removal, implantable contraceptive capsules 

$224 

11981 

Insertion, non-biodegradable drug delivery implant 

$156 

11982 

Contraceptive Capsule Removal 

$175 

11983 

Contraceptive Capsule Removal & Reinsert 

$221 

54050 

Condyloma Treatment (Destruct penis lesion(s)) 

$218 

56501 

Condyloma Treatment (Destruct vulva lesion(s) (simple <14) 

$301 

57170 

Diaphragm/Cervical Cap Fit  

$122 

57452 

Colposcopy 

$197 

57454 

Colposcopy And Biopsy 

$265 

58300 

Insertion of intrauterine device (IUD) 

$174 

58301 

Removal of intrauterine device (IUD) 

$173 

81002 

Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without 
microscopy 

$6 

81025 

Urine pregnancy test, by visual color comparison methods 

$15 

85018 

Hemoglobin (Hgb) (To bill this code providers must have their current CLIA-waiver certificates on file with 
MaineCare and update their provider enrollment with the Department.) 

$5 

86703 

HIV-1 and HIV-2, single assay (ex. Oraquick Advance Rapid ½. (If positive result, providers must recommend Western Blot confirmatory testing and collect a sample, blood or saliva, during the same encounter to send to an outside professional lab for testing.  Prepaid Kits to collect the sample are to be purchased from the Maine Center for Disease Control and Prevention, Health and Environmental Testing Laboratory in accordance with MaineCare Benefits Manual, Section 90.04-24). 

$24 

87210 

Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types; wet 
mount for infectious agents (e.g., saline, India ink, KOH preps) 

$10 

90471 

Immunization admin (Gardasil - 1st injection) 

$26 

96372 

Injection, therapeutic/prophylactic/diagnostic, sc/im 

$22 

99202 

Office or other outpatient visit for the evaluation and management of a new patient, which requires these three (3) key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend twenty (20) minutes face-to-face with the patient and/or family. 

$112 

99203 

Office or other outpatient visit for the evaluation and management of a new patient, which requires these three (3) key components: a detailed history; a detailed examination; and medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend thirty (30) minutes face-to-face with the 
patient and/or family. 

$173 

99204 

New Patient - Comprehensive 

$260 

99205 

New Patient - Complete 

$344 

99211 

Office or other outpatient visit for the evaluation and management of an established patient, that may not 
require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, five (5) minutes are spent performing or supervising these services. 

$35 

99212 

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two (2) of these three (3) key components: a problem focused history; a problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self-limited or minor. Physicians typically spend ten (10) minutes face-to-face with the patient and/or family. 

$87 

99213 

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two (2) of these three (3) key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend fifteen (15) minutes face-to-face with the patient and/or 
family. 

$141 

99214 

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two (2) of these three (3) key components: a detailed history; a detailed examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend twenty-five 
(25) minutes face-to-face with the patient and/or family. 

$199 

99215 

Continuing Patient - Complete 

$281 

99384 

Preventive visit, new, 12-17 

$209 

99385 

Initial comprehensive preventative medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient, adolescent age 18-39 years. (All providers of these services must meet all MaineCare Benefits Manual, Section 94 Early, Periodic, Screening, Diagnostic and Treatment (EPSDT) periodicity requirements for MaineCare members up to their twenty-first (21) birthday.) 

$203 

99386 

Preventive visit, new, 40-64 

$235 

99394 

Preventive visit, est, 12-17 

$178 

99395 

Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions and the ordering of appropriate laboratory/diagnostic procedures, established patient; age 18- 39 years. (All providers of these services must meet all MaineCare Benefits Manual, Section 94 Early, Periodic, Screening, Diagnostic and Treatment (EPSDT) periodicity requirements for MaineCare members up to their twenty-first (21) birthday.) 

$182 

99396 

Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions and the ordering of appropriate laboratory/diagnostic procedures, established patient; 40-64 years 

$195 

99401 

Individual Preventive Counseling: Approx. 15 minutes 

$60 

99402 

Individual Preventive Counseling: Approx. 30 minutes 

$100