How much does Medicare pay for CPT 86304?

Medicare allowed an average of $20.36 per service and paid $20.36 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $138.06, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 86304?

Immunologic analysis for detection of tumor antigen, quantitative; ca 125. It was billed 130,451 times to 62,313 Medicare beneficiaries by 507 providers in 2024.

Which specialty bills 86304 most?

Clinical Laboratory, with 97,841 services from 188 clinicians. Next are Pathology, Gynecological Oncology, Hematology-Oncology.

CPT 86304

Immunologic analysis for detection of tumor antigen, quantitative; ca 125

$20.36Medicare-allowed amount per service, averaged across 130,451 services

Providers submitted

$138.06

Asking price, not received

Medicare allowed

$20.36

The fee schedule figure

Medicare paid

$20.36

Balance is patient coinsurance

Providers submitted an average of $138.06 for this code and Medicare allowed $20.36 — 6.8× 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 $20.36 (100%); the rest is the patient’s coinsurance and deductible.

Services: 130,451
Beneficiaries: 62,313
Providers billing it: 507
Total allowed: $2,655,982

What Medicare pays for CPT 86304

Across 130,451 services billed by 507 providers to 62,313 beneficiaries, Medicare allowed an average of $20.36 per service. That is 2.1 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 86304

Specialty	Services	Beneficiaries	Avg allowed	Providers
Clinical Laboratory	97,841	50,385	$20.37	188
Pathology	9,491	3,002	$20.39	15
Gynecological Oncology	8,645	2,797	$20.27	55
Hematology-Oncology	7,503	2,819	$20.36	136
Medical Oncology	1,935	776	$20.38	41
Physician Assistant	1,475	676	$20.31	17
Obstetrics & Gynecology	1,286	658	$20.28	15
Nurse Practitioner	1,041	612	$20.32	19
Hematology	651	151	$20.36	7
Internal Medicine	301	171	$20.39	9
Cardiology	179	173	$20.39	1
Family Practice	46	46	$20.39	1
Hospitalist	26	19	$20.39	1
Certified Clinical Nurse Specialist	17	15	$20.39	1
Surgical Oncology	14	13	$20.39	1

86304 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
California	24,444	$20.38	$20.39	66
New Jersey	16,377	$20.36	$20.39	10
Florida	16,002	$20.37	$20.39	15
Texas	12,843	$20.32	$20.39	54
New York	7,618	$20.38	$20.39	60
Arizona	6,536	$20.36	$20.39	4
North Carolina	5,467	$20.39	$20.39	5
Kansas	3,653	$20.39	$20.39	3
Pennsylvania	2,741	$20.39	$20.39	13
Ohio	2,699	$20.38	$20.39	16
Tennessee	2,529	$20.29	$20.39	13
Maryland	2,519	$20.38	$20.38	22
Illinois	2,415	$20.36	$20.39	18
Washington	2,186	$20.39	$20.39	8
Virginia	2,176	$20.33	$20.39	20
Alabama	1,988	$20.37	$20.39	6
Minnesota	1,890	$20.37	$20.39	20
Oregon	1,679	$20.31	$20.39	23
Wisconsin	1,578	$20.09	$20.39	3
Massachusetts	1,383	$20.35	$20.39	4
Georgia	1,335	$20.39	$20.39	6
South Carolina	1,332	$20.21	$20.39	4
Oklahoma	1,225	$20.24	$20.39	10
Arkansas	997	$20.32	$20.39	22
Nevada	864	$20.37	$20.39	6
Hawaii	770	$20.34	$20.39	2
New Mexico	756	$20.39	$20.39	4
Iowa	726	$20.36	$20.39	11
Colorado	683	$20.39	$20.39	4
Michigan	578	$20.39	$20.39	7
Nebraska	506	$20.39	$20.39	12
Puerto Rico	419	$20.30	$20.39	9
Indiana	409	$20.30	$20.39	5
Utah	261	$20.39	$20.39	7
Connecticut	190	$20.24	$20.39	2
Louisiana	174	$20.39	$20.39	2
Maine	148	$20.39	$20.39	1
Wyoming	127	$20.39	$20.39	3
South Dakota	118	$20.39	$20.39	2
Mississippi	34	$20.39	$20.39	2
Kentucky	28	$20.39	$20.39	1
Rhode Island	26	$20.39	$20.39	1
North Dakota	22	$20.39	$20.39	1

Related codes

86334Immunologic analysis technique on serum (immunofixation)$19.86
86376Microsomal antibodies (autoantibody) measurement$14.24
86300Immunologic analysis for detection of tumor antigen$20.21
86364Measurement of tissue transglutaminase$11.29
86317Detection of infectious agent antibody$14.63
86335Immunologic analysis technique on body fluid$24.16
86301Immunologic analysis for detection of tumor antigen$20.37
86381Measurement of mitochondrial antibody$24.88
86360T cell count and ratio$45.96
86341Islet cell (pancreas) antibody measurement$23.07
86316Analysis for detection of tumor marker$20.36
86320Immunologic analysis technique on serum$22.61

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.