225 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 225, 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. 3 of the 6 states list more than one rate for 225, 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 6 states, 1 publish 225 per eapg weight and 1 per days (average length of stay), and 4 schedules print no unit at all (a flat amount per service).
• Per hour. 225 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. No Medicare physician fee schedule amount is on file for 225, so there is no percentage.
• Source and date. Each Source link opens the state's own document; “since” is the date the rate took effect.

Published rates for 225 run from $2.00 in New York to $13.42 in Wisconsin. The two publish it in different units (no unit printed versus days (average length of stay)), so part of that gap is the unit rather than the price. Half the states pay more than the median of $5.66 and half pay less. The usual reasons for a spread like this in hospital outpatient rates:

• States pay outpatient hospital care under different systems: grouped payments, a fee schedule or a percentage of charges.
• Many outpatient amounts are hospital-specific or adjusted by hospital type.

Timing matters too. 1 state set the current rate for 225 in 2026 or later, while 1 state 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.

What a plan pays for 225 is negotiated privately, but the state decides how much room there is to negotiate. Here is how the rules break down across the 6 states.

In 2 states, the published rate binds plans: a floor, a pass-through or a state-set rate. In 4 states, plans negotiate and the published rate is a benchmark or out-of-network default.

• Plans negotiate; the published rate applies out of network (3 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 (2 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.
• Suggested schedule for plans (1 state). Use the schedule as a public benchmark in negotiations; the actual rate is whatever you and the plan agree.

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 Wisconsin managed care.

225 is a revenue code in the hospital outpatient line, billed mostly by hospital outpatient departments. Revenue codes identify a facility's accommodation or cost center on an institutional claim. Day-rate services such as hospice and nursing facility care are billed per day under them.

Outpatient services are billed per procedure, and some systems package lower-cost items into the payment for the main service.

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.