97016 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 97016, 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. 32 of the 43 states list more than one rate for 97016, 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 43 states, 1 publish 97016 per unit and 1 per visit, and 41 schedules print no unit at all (a flat amount per service).
• Per hour. 97016 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. Shown only where the Medicaid rate uses the code's own billing unit and a Medicare amount exists: 1 state for 97016, at 37%.
• Source and date. Each Source link opens the state's own document; “since” is the date the rate took effect.

Published rates for 97016 run from $4.26 in Kentucky to $24.67 in Nebraska. The two publish it in different units (no unit printed versus visit), so part of that gap is the unit rather than the price. Half the states pay more than the median of $11.04 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.
• 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.
• 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. 29 states set the current rate for 97016 in 2026 or later, while 9 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 97016. 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 8 states, the published rate binds plans: a floor, a pass-through or a state-set rate. In 23 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 11 states is not classified yet.

• Plans negotiate; the published rate applies out of network (23 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 (8 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 Nebraska managed care.

97016 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.

Where a state publishes separate facility and non-facility amounts, the non-facility (office) amount is usually higher because the practice carries the overhead. 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 $11.15–$15.25 for 97016 (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.