81216 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 81216, 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. 15 of the 41 states list more than one rate for 81216, 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 41 states, 1 publish 81216 per unit and 1 per a, and 39 schedules print no unit at all (a flat amount per service).
• Per hour. 81216 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 81216, 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 81216 run from $13.50 in Arizona to $1,760.70 in Iowa. The two publish it in different units (no unit printed versus A), so part of that gap is the unit rather than the price. Half the states pay more than the median of $166.61 and half pay less. The usual reasons for a spread like this in lab & pathology rates:

• 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.
• Pathology services with an interpretation have professional and technical components that states price separately.

Timing matters too. 10 states set the current rate for 81216 in 2026 or later, while 17 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.

Most Medicaid members are in managed-care plans, and plans don't publish their provider fee schedules. For 81216, the public signal is the rule each state sets for its plans, recorded on each rate above.

In 7 states, the published rate binds plans: a floor, a pass-through or a state-set rate. In 21 states, plans negotiate and the published rate is a benchmark or out-of-network default (or a ceiling). The rule for the remaining 13 states is not classified yet.

• Plans negotiate; the published rate applies out of network (20 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.
• Plans may pay no more than the published rate (1 state). Expect offers at or below the published rate. Higher payment would have to come from something other than the base rate, such as a quality or value-based arrangement.

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 Iowa managed care.

81216 is a CPT pathology and laboratory code in the lab & pathology line, billed mostly by independent laboratories, hospital labs and pathology groups. Laboratory codes are paid per test; a panel is paid as one code, not as the sum of its tests. Pathology codes with an interpretation can be split into professional and technical components.

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.