M0243 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 M0243, 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. 4 of the 11 states list more than one rate for M0243, 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, 1 publish M0243 per hour, and 10 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). 1 of the 11 states bill M0243 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. No Medicare physician fee schedule amount is on file for M0243, 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 M0243 run from $34.59 in Texas to $477.00 in New Mexico. The two publish it in different units (no unit printed versus hour), so part of that gap is the unit rather than the price. Half the states pay more than the median of $413.61 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. None of the states changed its rate for M0243 in 2026, while 7 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 M0243. 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 2 states, the published rate binds plans: a floor, a pass-through or a state-set rate. 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 2 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.
• Plans must pay at least the published rate (2 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.
• 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 New Mexico managed care.

M0243 is a billing code in the physician & professional line, billed mostly by physicians, nurse practitioners, physician assistants and other licensed practitioners. This code is billed per service as the state's schedule defines it.

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.

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.