97010 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 97010, 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. 18 of the 25 states list more than one rate for 97010, 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 25 states, 1 publish 97010 per 15 min, and 24 schedules print no unit at all (a flat amount per service).
• Per hour. Time-based units are converted to an hour of service (four 15-minute units make an hour). 1 of the 25 states bill 97010 by time.
• 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 97010, 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 97010 run from $3.68 in North Carolina to $25.18 in New Hampshire, a 6.8x gap in the same unit. Half the states pay more than the median of $6.95 and half pay less. The usual reasons for a spread like this in physician & professional rates:

• 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.
• 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. 12 states set the current rate for 97010 in 2026 or later, while 6 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 97010. 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 6 states, the published rate binds plans: a floor, a pass-through or a state-set rate. In 13 states, plans negotiate and the published rate is a benchmark or out-of-network default. In 1 state, the service is paid outside the plans or through a state-directed payment. The rule for the remaining 5 states is not classified yet.

• Plans negotiate; the published rate applies out of network (13 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 (6 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.
• Paid by the state, outside the plans (1 state). Bill the state's Medicaid program, not the plan, at the published rate. There is no plan contract to negotiate for this service.

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.

97010 is a CPT medicine code in the physician & professional line, billed mostly by physicians, nurse practitioners, physician assistants and other licensed practitioners. The medicine section runs from vaccines and psychiatry to dialysis, cardiology and therapy. Some of its codes are timed in 15-minute units, others are billed once per session or per test, so the unit matters more here than in most sections.

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. Where a state publishes separate facility and non-facility amounts, the non-facility (office) amount is usually higher because the practice carries the overhead.

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.