0042U 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 0042U, 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. 1 of the 9 states list more than one rate for 0042U, 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 9 schedules prints a separate unit for 0042U, so each amount is a flat payment for one service as the code defines it.
• Per hour. 0042U 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 0042U, 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 0042U run from $4.30 in Kansas to $17.21 in Arizona, a 4.0x gap in the same unit. Half the states pay more than the median of $15.49 and half pay less. The usual reasons for a spread like this in lab & pathology rates:

• Fees for newer molecular and genetic tests are often set case by case, so fewer states publish them and the published amounts spread widely.
• Many states set clinical laboratory fees with reference to the Medicare Clinical Laboratory Fee Schedule, but at different percentages and from different update years.
• Some states bundle certain tests into panels or into facility payments, so the separately billable amount differs.

Timing matters too. 6 states set the current rate for 0042U 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 0042U is negotiated privately, but the state decides how much room there is to negotiate. Here is how the rules break down across the 9 states.

In 1 state, 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. 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 (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 Arizona managed care.

0042U is a CPT proprietary laboratory analysis code in the lab & pathology line, billed mostly by independent laboratories, hospital labs and pathology groups. PLA codes identify a specific laboratory's test and are paid per test.

Pathology interpretation can be billed with modifier 26 when the laboratory and the pathologist bill separately. Laboratory tests are billed per test, and a panel is paid as a single code rather than as the sum of its component tests.

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.