C5275 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 C5275, 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. Each state lists a single rate for C5275.
• Unit. None of the 5 schedules prints a separate unit for C5275, so each amount is a flat payment for one service as the code defines it.
• Per hour. C5275 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. No Medicare physician fee schedule amount is on file for C5275, so there is no percentage.
• Source and date. Each Source link opens the state's own document; “since” is the date the rate took effect.

Published rates for C5275 run from $176.34 in Utah to $546.91 in Rhode Island, a 3.1x gap in the same unit. Half the states pay more than the median of $317.31 and half pay less. The usual reasons for a spread like this in hospital outpatient rates:

• Many outpatient amounts are hospital-specific or adjusted by hospital type.
• States pay outpatient hospital care under different systems: grouped payments, a fee schedule or a percentage of charges.

Timing matters too. 2 states set the current rate for C5275 in 2026 or later, while 1 state 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 C5275 is negotiated privately, but the state decides how much room there is to negotiate. Here is how the rules break down across the 5 states.

In 1 state, the published rate binds plans: a floor, a pass-through or a state-set rate. In 4 states, plans negotiate and the published rate is a benchmark or out-of-network default.

• Plans negotiate; the published rate applies out of network (4 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 (1 state). 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 Rhode Island managed care.

C5275 is a HCPCS Level II hospital outpatient code in the hospital outpatient line, billed mostly by hospital outpatient departments. C codes were created for Medicare's hospital outpatient payment system. Medicaid programs that use them generally pay them on a hospital outpatient schedule rather than a physician schedule.

Outpatient services are billed per procedure, and some systems package lower-cost items into the payment for the main service.

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.