97116 Medicaid reimbursement rate by state (2026)

• Order. States are listed from the highest published rate to the lowest. A like-for-like rank only counts states that use the same unit: 45 of the 46 states publish 97116 per 15 min, enough to rank them against each other.
• Medicaid rate. The most the state's fee-for-service program pays for one unit, as published. 34 of the 46 states list more than one rate for 97116, 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 46 states, 45 publish 97116 per 15 min and 1 per unit.
• Per hour. Time-based units are converted to an hour of service (four 15-minute units make an hour). 45 of the 46 states bill 97116 by time, with a median of $93.80 per hour.
• 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: 42 states for 97116, at between 29% and 148%.
• Source and date. Each Source link opens the state's own document; “since” is the date the rate took effect.

Published rates for 97116 run from $8.38 in Pennsylvania to $44.17 in Alaska, a 5.3x gap in the same unit. Half the states pay more than the median of $23.47 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.
• 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. 30 states set the current rate for 97116 in 2026 or later, while 8 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.

Most Medicaid members are in managed-care plans, and plans don't publish their provider fee schedules. For 97116, the public signal is the rule each state sets for its plans, recorded on each rate above.

In 8 states, the published rate binds plans: a floor, a pass-through or a state-set rate. In 24 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 13 states is not classified yet.

• Plans negotiate; the published rate applies out of network (24 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 Alaska managed care.

97116 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.

Physician-fee-schedule codes are billed per service: one unit is one occurrence unless the code itself is defined by time or quantity. Where a state publishes separate facility and non-facility amounts, the non-facility (office) amount is usually higher because the practice carries the overhead.

Medicare's 2026 physician fee schedule pays $27.07–$37.31 for 97116 (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.