Expected-payment calculator
Enter a code, date of service, locality, and setting to see the expected Medicare allowed amount, the 80/20 split, sequestration, and — if you enter what the payer actually paid — the variance.
- Allowed amount
- $135.61
- Medicare portion (80%)
- $108.49
- Sequestration (−2%)
- −$2.17
- Medicare pays
- $106.32
- Patient / secondary (20%)
- $27.12
- Total expected to provider
- $133.44
How this amount is computed
allowed = (work·RVU × work·GPCI + PE·RVU × PE·GPCI + MP·RVU × MP·GPCI) × conversion factor, using the non-facility practice-expense column.
| Component | RVU | GPCI | Subtotal |
|---|---|---|---|
| Work | 1.92 | 1.000 | 1.920 |
| Practice expense (non-facility) | 2.00 | 1.000 | 2.000 |
| Malpractice | 0.14 | 1.000 | 0.140 |
| × conversion factor $33.4009 = allowed | $135.61 | ||
99214 — 2026 C · National (GPCI 1.000) · Non-facility (office) Allowed amount: $135.61 Medicare pays: $106.32 Patient / secondary (20%): $27.12 Total expected to provider: $133.44
Allowed = locality-adjusted, before sequestration. Sequestration applies to the Medicare 80% portion. See the full 99214 page and how Medicare pays.
Get this rate by API
The same number, programmatically — the bulk endpoint returns the payable amount, status, the release that answered it, and full citations (CMS file, row, and the math) for every code in one call. Shown here with one code; batch up to 500 per request.
curl -X POST -H "Authorization: Bearer $API_KEY" \
-H "Content-Type: application/json" \
-d '{"codes":["99214"],"setting":"non_facility","year":2026,"quarter":"C","sequestration":true}' \
"https://medicalfeeschedules.com/v1/rates/bulk""locality"
to the request body for a locality-adjusted rate — the calculator has a searchable locality picker.
This is a single-line calculator. Batch reconciliation (upload a remittance or a CSV of claims to flag underpayments across a whole book), modifier-adjusted pricing, and API access are on the roadmap.