21125 Medicaid reimbursement rate by state (2026)

• Order. States are listed from the highest published rate to the lowest. No single unit is shared by 8 or more states for 21125, so the order is by published amount and is not a like-for-like rank.
• Medicaid rate. The most the state's fee-for-service program pays for one unit, as published. 38 of the 48 states list more than one rate for 21125, by modifier, provider type or setting; the table shows the one that matches the provider level and setting used across states, without add-ons.
• Unit. Of the 48 states, 2 publish 21125 per unit, and 46 schedules print no unit at all (a flat amount per service).
• Per hour. 21125 is not billed in time units in these states, so no hourly figure is shown.
• Managed-care plans. The rule the state sets for its plans on this rate. What each rule means is explained below.
• % of Medicare. Medicare amounts exist for 21125, but no state's Medicaid unit matches Medicare's billing unit closely enough to compute a percentage.
• Source and date. Each Source link opens the state's own document; “since” is the date the rate took effect.

Published rates for 21125 run from $39.90 in Rhode Island to $4,670.81 in Alabama, a 117.1x gap in the same unit. Half the states pay more than the median of $1,158.31 and half pay less. The usual reasons for a spread like this in physician & professional rates:

• Many schedules pay differently by place of service (office versus facility) and by practitioner, and nurse practitioners and physician assistants are often paid a percentage of the physician amount.
• Each state sets its own physician conversion factor or fee for every code, and many update them on a state budget cycle rather than on Medicare's calendar.
• Some states pay physician services as a percentage of the Medicare fee schedule; others keep a schedule of their own that may not have been rebased for years.

Timing matters too. 28 states set the current rate for 21125 in 2026 or later, while 10 states still pay a rate that took effect in 2022 or earlier. A state that has not updated its rate in years will drift down the ranking as others raise theirs.

No managed-care plan publishes what it pays for 21125. What is public is the rule each state's plan contracts set, and that rule decides how much the published rate matters when you contract with a plan.

In 11 states, the published rate binds plans: a floor, a pass-through or a state-set rate. In 22 states, plans negotiate and the published rate is a benchmark or out-of-network default. The rule for the remaining 15 states is not classified yet.

• Plans negotiate; the published rate applies out of network (22 states). In-network rates can be above or below the published rate. The published rate is the benchmark both sides know, and the fallback if no contract is signed.
• Plans must pay at least the published rate (11 states). The published rate is your floor. Negotiate up from it, and if a plan pays less, the contract provision is the basis for a payment dispute.

Plan-negotiated rates are never estimated here. To see the rule and its citation for a particular state, open that state's managed-care page, for example Alabama managed care.

21125 is a CPT surgery code in the physician & professional line, billed mostly by physicians, nurse practitioners, physician assistants and other licensed practitioners. Surgical codes are paid once per procedure. The fee can include a global period of related care before and after the procedure, and modifiers for multiple, bilateral or assistant procedures raise or reduce what is actually paid.

Physician-fee-schedule codes are billed per service: one unit is one occurrence unless the code itself is defined by time or quantity. Practitioners who are not physicians are often paid a reduced percentage of the published amount, so check the schedule for the reduction that applies to your provider type.

Medicare's 2026 physician fee schedule pays $2,265.30–$3,105.96 for 21125 (non-facility), depending on the Medicare locality. That is a useful reference point, but Medicare and Medicaid can define the unit differently, so compare only where the units match.

Before billing, confirm the rate, unit and any modifier with the state's current schedule or the plan: the amounts here are as published, not a guarantee of payment.