How much does Medicare pay for CPT 86226?

Medicare allowed an average of $11.78 per service and paid $11.78 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $49.65, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 86226?

Measurement of dna antibody, single stranded. It was billed 17,625 times to 15,057 Medicare beneficiaries by 214 providers in 2024.

Which specialty bills 86226 most?

Rheumatology, with 14,686 services from 165 clinicians. Next are Physician Assistant, Nurse Practitioner, Clinical Laboratory.

CPT 86226

Measurement of dna antibody, single stranded

$11.78Medicare-allowed amount per service, averaged across 17,625 services

Providers submitted

$49.65

Asking price, not received

Medicare allowed

$11.78

The fee schedule figure

Medicare paid

$11.78

Balance is patient coinsurance

Providers submitted an average of $49.65 for this code and Medicare allowed $11.78 — 4.2× less. That gap is normal and means nothing on its own: Medicare pays its fee schedule regardless of what is billed, so the submitted figure describes a hospital chargemaster, not a price anyone paid. Of the allowed amount Medicare paid $11.78 (100%); the rest is the patient’s coinsurance and deductible.

Services: 17,625
Beneficiaries: 15,057
Providers billing it: 214
Total allowed: $207,623

What Medicare pays for CPT 86226

Across 17,625 services billed by 214 providers to 15,057 beneficiaries, Medicare allowed an average of $11.78 per service. That is 1.2 services per beneficiary, so this is a code patients typically receive more than once. The allowed amount is the figure that matters: it is what Medicare and the patient together owe, set by the fee schedule and adjusted for local practice costs. What a provider chose to submit has no bearing on it.

Who bills 86226

Specialty	Services	Beneficiaries	Avg allowed	Providers
Rheumatology	14,686	12,566	$11.77	165
Physician Assistant	1,718	1,329	$11.81	12
Nurse Practitioner	707	662	$11.76	22
Clinical Laboratory	196	185	$11.87	3
Internal Medicine	193	193	$11.77	5
Hospitalist	40	38	$11.87	1
Gastroenterology	32	31	$11.62	2
Pediatric Medicine	31	31	$11.87	2
Family Practice	11	11	$11.87	1
Hand Surgery	11	11	$11.87	1

86226 reimbursement by state

Two different numbers. Allowed is what Medicare actually allowed in that state, which includes the local practice-cost adjustment. Standardized strips that geographic adjustment out of the payment, so it is the column to use when comparing states — a difference there reflects how the code was billed, not what it costs to run a practice locally.

State	Services	Allowed	Standardized pmt	Providers
Texas	3,338	$11.68	$11.87	14
California	2,398	$11.84	$11.87	17
Florida	2,010	$11.81	$11.86	23
Illinois	1,435	$11.85	$11.87	10
Maryland	934	$11.73	$11.87	17
Kentucky	895	$11.71	$11.87	12
Georgia	778	$11.79	$11.87	16
North Carolina	737	$11.82	$11.87	12
Missouri	661	$11.79	$11.87	1
South Carolina	581	$11.86	$11.87	10
New York	501	$11.87	$11.87	5
New Jersey	430	$11.87	$11.87	3
Arkansas	379	$11.61	$11.87	5
Virginia	279	$11.79	$11.87	5
Idaho	267	$11.79	$11.87	4
Pennsylvania	260	$11.87	$11.87	4
Nebraska	257	$11.61	$11.87	5
New Mexico	222	$11.73	$11.87	2
Minnesota	198	$11.67	$11.87	9
Kansas	159	$11.87	$11.87	5
Oregon	126	$11.72	$11.87	2
Alabama	113	$11.81	$11.87	5
Iowa	113	$11.87	$11.87	4
Arizona	101	$11.87	$11.87	5
Tennessee	95	$11.75	$11.87	4
Indiana	93	$11.87	$11.87	5
Washington	73	$11.87	$11.87	3
Ohio	58	$11.52	$11.87	2
Oklahoma	58	$11.71	$11.87	1
Mississippi	52	$11.71	$11.87	2
Louisiana	24	$11.54	$11.87	2

Related codes

86235Measurement of antibody for assessment of autoimmune disorder$17.49
86200Measurement of antibody for rheumatoid arthritis assessment$12.64
86225Measurement of dna antibody$13.43
86258Detection of gliadin (deamidated) (dgp) antibody$11.80
86255Screening test for antibody to noninfectious agent$12.39
86231Detection of endomysial antibody (ema)$11.84
86256Measurement of antibody to noninfectious agent$12.40
86294Immunologic analysis for detection of tumor antigen$25.01
86215Measurement of dna antibody$12.96

Billing this code is not the same as earning it

An allowed amount is revenue to a practice, not income to a clinician. It funds staff, premises, equipment and supplies before anyone is paid. What clinicians actually earn is published separately by the Department of Labor, and what industry pays them is published separately again by CMS — this site carries both.

What doctors are paid →·Look up a clinician →·All procedure codes →

Where this comes from. CMS Medicare Physician & Other Practitioners, by Provider and Service, 2024. It covers fee-for-service Original Medicare Part B only — not Medicare Advantage, not Medicaid, and not commercial insurance, which typically pays more for the same code.

How it is averaged. CMS publishes one average per provider per code. Every figure here is re-weighted by the number of services, so a clinician who billed the code 4,000 times counts 4,000 times more than one who billed it twice. CMS also suppresses any provider-code pair with fewer than 11 beneficiaries, so low-volume practice is missing from these totals by design.