55869 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 55869, 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. 24 of the 38 states list more than one rate for 55869, 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 38 states, 2 publish 55869 per unit, and 36 schedules print no unit at all (a flat amount per service).
• Per hour. 55869 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 55869, 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 55869 run from $205.26 in Rhode Island to $3,490.83 in New Hampshire, a 17.0x gap in the same unit. Half the states pay more than the median of $1,060.01 and half pay less. The usual reasons for a spread like this in physician & professional rates:

• Primary-care and pediatric add-ons, enhanced rates for certain specialties and targeted increases for access problems change individual codes without moving the rest of the schedule.
• 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.
• Modifiers such as professional or technical component, bilateral, multiple procedure and assistant at surgery change the amount paid, and states apply them with their own percentages.

Timing matters too. 38 states set the current rate for 55869 in 2026 or later. A state that has not updated its rate in years will drift down the ranking as others raise theirs.

What a plan pays for 55869 is negotiated privately, but the state decides how much room there is to negotiate. Here is how the rules break down across the 38 states.

In 7 states, the published rate binds plans: a floor, a pass-through or a state-set rate. In 19 states, plans negotiate and the published rate is a benchmark or out-of-network default. The rule for the remaining 12 states is not classified yet.

• Plans negotiate; the published rate applies out of network (19 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 (7 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 New Hampshire managed care.

55869 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.

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. Physician-fee-schedule codes are billed per service: one unit is one occurrence unless the code itself is defined by time or quantity.

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.