CPT 81264 Fee Schedule
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.
| Key Fact | Detail |
|---|---|
| Service Type | Genetic Analysis Procedures Tier 1 Molecular Pathology Procedures |
| Common Place of Service | 81 - Independent Laboratory 22 - On Campus Outpatient Hospital |
| Common Modifiers | None XU - Unusual Non-Overlapping Service XE - Separate encounter |
| Complexity Level | Low |
| Medicare Fee Schedule | View Medicare rates for 81264 |
National average reimbursement for CPT 81264 by major payers:
$142.04
$114.37
$167.96
$271.95
| Payer | Code | Rate | NPI | Tax ID | State | Specialty |
|---|---|---|---|---|---|---|
United | 81264 | $172.73 | 1073502985 - CHU CHEN | 42484572 - MERRIMACK VALLEY PEDIATRIC ASSOCIATES, INC. | MA | Pediatrics Physician (208000000X) |
United | 81264 | $224.19 | 1437126745 - ALAN MELTZER | 521958352 - ATLANTIC HEALTH SYSTEM INC | NJ | Pediatrics Physician (208000000X) |
United | 81264 | $151.05 | 1972501252 - BAYCARE HOME CARE, INC. | 593582520 - (FL) BAYCARE HOME CARE INC | FL | Home Health Agency (251E00000X) |
United | 81264 | $380.01 | 1073502985 - CHU CHEN | 42484572 - MERRIMACK VALLEY PEDIATRIC ASSOCIATES, INC. | MA | Pediatrics Physician (208000000X) |
United | 81264 | $151.05 | 1720087513 - BAYCARE HOME CARE, INC. | 593582520 - (FL) BAYCARE HOME CARE INC | FL | Home Health Agency (251E00000X) |
United | 81264 | $380.01 | 1073502985 - CHU CHEN | 42484572 - MERRIMACK VALLEY PEDIATRIC ASSOCIATES, INC. | MA | Pediatrics Physician (208000000X) |
United | 81264 | $103.64 | 1497944565 - MICHAEL SHULER | 581076549 - ATHENS ORTHOPEDIC CLINIC, PA | GA | Orthopaedic Hand Surgery Physician (207XS0106X) |
United | 81264 | $259.10 | 1003166612 - MATTHEW LILLEY | 680637976 - BEND MEMORIAL CLINIC, PC | OR | Orthopaedic Surgery Physician (207X00000X) |
United | 81264 | $72.55 | 1053866707 - BRITTANY PTACHICK | 541958039 - HROA 401K PLAN | VA | Family Nurse Practitioner (363LF0000X) |
United | 81264 | $81.48 | 1366400376 - SUNRISE HOME HEALTH CARE INC. | 650307774 - (FL) SUNRISE HOME HEALTH CARE INC | FL | Home Health Agency (251E00000X) |
United | 81264 | $230.91 | 1982994224 - OVERLOOK HOSPITAL | 521958352 - ATLANTIC HEALTH SYSTEM INC | NJ | Primary Care Clinic/Center (261QP2300X) |
United | 81264 | $122.23 | 1578583647 - MARC STIEFEL | 202604678 - PINNACLE ENT ALLIANCE, LLC | PA | Otolaryngology Physician (207Y00000X) |
United | 81264 | $85.43 | 1366428401 - AARON ASKEW | 911750212 - DESERT BONE & JOINT SPECIALISTS, LLP | OR | Orthopaedic Trauma Physician (207XX0801X) |
United | 81264 | $103.64 | 1497944565 - MICHAEL SHULER | 581076549 - ATHENS ORTHOPEDIC CLINIC, P.A. | GA | Orthopaedic Hand Surgery Physician (207XS0106X) |
United | 81264 | $60.45 | 1598375651 - E AND A MEDICAL ON THE GO HEALTHCARE OF SOUTH FLORIDA LLC, E AND A HEALTHCARE ON THE GO | 832289173 - (FL) E AND A MEDICAL ON THE GO HEALTHCARE OF SOUTH FLORIDA LLC | FL | Home Health Agency (251E00000X) |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
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CPT 81264 vs. Other Tier 1 Molecular Pathology Procedures Codes
The CPT 81264 code is part of the Genetic Analysis Procedures services used for Tier 1 Molecular Pathology Procedures. 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 81264 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 |
|---|---|---|
| 81261-CPT | Low | Igh Gene Rearrange Amp Meth, Igh Immunoglobulin Heavy Chain Locus Eg Leukemias And Lymphomas B Cell Gene Rearrangement Analysis To Detect Abnormal Clonal Population S Amplified Methodology Eg Polymerase Chain Reaction |
| 81262-CPT | Low | Igh Gene Rearrang Dir Probe, Igh Immunoglobulin Heavy Chain Locus Eg Leukemias And Lymphomas B Cell Gene Rearrangement Analysis To Detect Abnormal Clonal Population S Direct Probe Methodology Eg Southern Blot |
| 81263-CPT | Moderate | Igh@ (Immunoglobulin Kappa Light Chain Locus) (Eg, Leukemia And Lymphoma, B-Cell), Gene Rearrangement Analysis, Evaluation To Detect Abnormal Clonal Population(S) |
| 81264-CPT | Low | Igk Rearrangeabn Clonal Pop, Igk Immunoglobulin Kappa Light Chain Locus Eg Leukemia And Lymphoma B Cell Gene Rearrangement Analysis Evaluation To Detect Abnormal Clonal Population S |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 81264. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 81264 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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