97813 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 97813, 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. 7 of the 11 states list more than one rate for 97813, 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 11 states, 2 publish 97813 per 15 min, and 9 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). 2 of the 11 states bill 97813 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. Medicare amounts exist for 97813, but no state's Medicaid unit matches Medicare's billing unit closely enough to compute a percentage.
• Source and date. Each Source link opens the state's own document; “since” is the date the rate took effect.

Published rates for 97813 run from $17.50 in District of Columbia to $43.22 in Minnesota, a 2.5x gap in the same unit. Half the states pay more than the median of $24.37 and half pay less. The usual reasons for a spread like this in physician & professional rates:

• 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.
• 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.

Timing matters too. 6 states set the current rate for 97813 in 2026 or later, while 2 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 97813, the public signal is the rule each state sets for its plans, recorded on each rate above.

In 6 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 4 states is not classified yet.

• Plans negotiate; the published rate applies out of network (6 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.
• 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 Minnesota managed care.

97813 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 $53.85–$71.68 for 97813 (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.