99454 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 99454, 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. 20 of the 32 states list more than one rate for 99454, 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, 2 publish 99454 per unit and 1 per visit, and 29 schedules print no unit at all (a flat amount per service).
• Per hour. 99454 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 99454, at 58%.
• Source and date. Each Source link opens the state's own document; “since” is the date the rate took effect.

Published rates for 99454 run from $14.58 in Kansas to $73.24 in Montana, a 5.0x gap in the same unit. Half the states pay more than the median of $39.82 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.
• 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.

Timing matters too. 24 states set the current rate for 99454 in 2026 or later, while 3 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.

What a plan pays for 99454 is negotiated privately, but the state decides how much room there is to negotiate. Here is how the rules break down across the 32 states.

In 7 states, the published rate binds plans: a floor, a pass-through or a state-set rate. In 15 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 9 states is not classified yet.

• Plans negotiate; the published rate applies out of network (15 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 (7 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.
• State-directed payment (1 state). Eligible providers receive the directed amount on top of, or as a floor under, negotiated rates. Check whether your provider class qualifies.

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.

99454 is a CPT evaluation and management code in the physician & professional line, billed mostly by physicians, nurse practitioners, physician assistants and other licensed practitioners. Evaluation and management codes are billed once per visit. The code itself sets the level of the visit, so there is no time unit to multiply, and the setting (office, hospital, facility) decides which code applies.

Where a state publishes separate facility and non-facility amounts, the non-facility (office) amount is usually higher because the practice carries the overhead. 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 $44.64–$74.83 for 99454 (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.