97804 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: 31 of the 32 states publish 97804 per 30 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. 26 of the 32 states list more than one rate for 97804, 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 32 states, 31 publish 97804 per 30 min and 1 per unit.
• Per hour. Time-based units are converted to an hour of service (four 15-minute units make an hour). 31 of the 32 states bill 97804 by time, with a median of $26.24 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: 28 states for 97804, at between 20% and 144%.
• Source and date. Each Source link opens the state's own document; “since” is the date the rate took effect.

Published rates for 97804 run from $3.25 in Kansas to $23.94 in Montana, a 7.4x gap in the same unit. Half the states pay more than the median of $13.23 and half pay less. The usual reasons for a spread like this in physician & professional rates:

• 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.
• 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.
• 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.

Timing matters too. 20 states set the current rate for 97804 in 2026 or later, while 4 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 97804. 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 14 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 (14 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.

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 Montana managed care.

97804 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. Physician-fee-schedule codes are billed per service: one unit is one occurrence unless the code itself is defined by time or quantity.

Medicare's 2026 physician fee schedule pays $16.06–$21.49 for 97804 (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.