99497 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 99497, 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 27 states list more than one rate for 99497, 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. None of the 27 schedules prints a separate unit for 99497, so each amount is a flat payment for one service as the code defines it.
• Per hour. 99497 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. Medicare amounts exist for 99497, 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 99497 run from $23.66 in Kansas to $156.99 in Alaska, a 6.6x gap in the same unit. Half the states pay more than the median of $71.33 and half pay less. The usual reasons for a spread like this in physician & professional rates:

• 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.
• 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. 17 states set the current rate for 99497 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 99497. 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 5 states, the published rate binds plans: a floor, a pass-through or a state-set rate. In 13 states, plans negotiate and the published rate is a benchmark or out-of-network default. The rule for the remaining 9 states is not classified yet.

• Plans negotiate; the published rate applies out of network (13 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 (5 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 Alaska managed care.

99497 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.

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 $82.11–$112.74 for 99497 (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.