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See a sample rate comparisonCPT 80204 Fee Schedule
Last Verified: October 2026
Healthcare providers use this code to document and receive reimbursement for visits that address moderate-level medical decision-making, often including multiple diagnoses or prescription management.
Methotrexate Monitoring, This Test Measures The Therapeutic Level Of Methotrexate A Drug Used In The Treatment Of Rheumatoid Arthritis And Certain Types Of Cancer.
| Key Fact | Detail |
|---|---|
| Service Type | Pathology and Laboratory Procedures Therapeutic Drug Assays |
| Common Place of Service | 21 - Inpatient Hospital 81 - Independent Laboratory |
| Common Modifiers | 26 - Professional component 90 - Reference Laboratory |
| Complexity Level | Low |
| Medicare Fee Schedule | $38.57 national lab fee schedule rate (2026) · View Medicare rates for 80204 |
| Medicaid Fee Schedule | $35.485 median of the 8 states in the free preview · View Medicaid rates for 80204 |
National average reimbursement for CPT 80204 by major payers:
$30.31
$23.09
$38.70
$81.57
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CPT 80204
5 of 25 sample ratesHigher to lower in this preview
Chu Chen
Merrimack Valley Pediatric Associates, Inc.
$84.85Published rateChristopher Raio
St Joseph Hospital
$45.82Published rateChristopher Raio
St Francis Hospital
$38.53Published rateChristopher Raio
Mercy Medical Center
$23.14Published rateSunrise Home Health Care Inc.
Sunrise Home Health Care Inc
$15.43Published rate
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See a sample payer proposalCPT 80204 vs. Other Therapeutic Drug Assays Codes
The CPT 80204 code is part of the Pathology and Laboratory Procedures services used for Therapeutic Drug Assays. It represents a moderate-complexity encounter and is one of several codes that vary based on time spent, level of medical decision-making, and documentation requirements.
The CPT 80204 code involves more provider time and moderate medical decision-making, unlike lower-level codes that require less time and simpler assessments. It typically includes multiple diagnoses, medication management, or test interpretation, leading to higher reimbursement and more detailed documentation requirements.
| Code | Complexity | Description |
|---|---|---|
| 80187-CPT | Low | Posaconazole, A Lab Test For Posaconazole. This Drug Is Typically Used To Treat Or Prevent Fungal Infections. |
| 80193-CPT | Low | Leflunomide Monitoring, This Test Measures The Therapeutic Level Of Leflunomide A Drug That Is Used To Treat Rheumatoid Arthritis In Adults. |
| 80197-CPT | Low | Immune Suppressant Monitoring, Monitoring Of An Immune Suppressant Drug To Help Prevent Transplant Rejection. |
| 80204-CPT | Low | Methotrexate Monitoring, This Test Measures The Therapeutic Level Of Methotrexate A Drug Used In The Treatment Of Rheumatoid Arthritis And Certain Types Of Cancer. |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 80204. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 80204 fee schedule helps patients estimate costs and providers optimize billing for accurate reimbursements.
Factors that affect fee schedules
Medicare & Medicaid Rates
Government-set reimbursement amounts
Private Insurance Rates
Negotiated rates between providers and insurance companies
Geographic Location
Costs may be higher in urban areas.
Provider Type
Hospital providers may have different rates than private practice.
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