Medicare expected-payment calculator

Enter one claim line. Localis resolves the applicable fee-schedule release and payment locality, then shows the expected allowed amount, Medicare payment, patient share, and source calculation.

Only have an RVU figure? Convert RVUs to dollars.

Calculate the expected fee-schedule amount

Enter one line item. Localis resolves the release and locality, then shows the expected allowed amount, Medicare payment, and source math.

CPT / HCPCS code

Date of service

Used to select the release in effect on the claim date.

Service ZIP

ZIP

Locality

Preferred: resolves the Medicare payment locality for this line.

Setting

+ Add modifier

Modifier

Single-line modifiers only. -51 requires a multi-line claim and belongs in the MPPR calculator.

Pricing -51? Use the MPPR calculator.

Advanced assumptions

2026 C · national baseline · standard conversion factor · sequestration on

Release override

Use only when checking an older adjudication or a specific quarter.

Manual locality override

No results found

No override

00 — Alabama (AL)

01 — Alaska (AK)

00 — Arizona (AZ)

13 — Arkansas (AR)

01 — Atlanta (GA)

31 — Austin (TX)

54 — Bakersfield (CA)

01 — Baltimore/Surr. Counties (MD)

20 — Beaumont (TX)

09 — Brazoria (TX)

16 — Chicago (IL)

55 — Chico (CA)

01 — Colorado (CO)

00 — Connecticut (CT)

11 — Dallas (TX)

01 — Dc + Md/Va Suburbs (DC)

01 — Delaware (DE)

01 — Detroit (MI)

12 — East St. Louis (IL)

71 — El Centro (CA)

03 — Fort Lauderdale (FL)

28 — Fort Worth (TX)

56 — Fresno (CA)

15 — Galveston (TX)

57 — Hanford-Corcoran (CA)

01 — Hawaii, Guam (HI)

18 — Houston (TX)

00 — Idaho (ID)

00 — Indiana (IN)

00 — Iowa (IA)

00 — Kansas (KS)

00 — Kentucky (KY)

18 — Los Angeles-Long Beach-Anaheim (Los Angeles/Orange County) (CA)

58 — Madera (CA)

01 — Manhattan (NY)

59 — Merced (CA)

01 — Metropolitan Boston (MA)

02 — Metropolitan Kansas City (MO)

01 — Metropolitan Philadelphia (PA)

01 — Metropolitan St. Louis (MO)

04 — Miami (FL)

00 — Minnesota (MN)

00 — Mississippi (MS)

60 — Modesto (CA)

01 — Montana (MT)

51 — Napa (CA)

00 — Nebraska (NE)

00 — Nevada (NV)

40 — New Hampshire (NH)

05 — New Mexico (NM)

01 — New Orleans (LA)

00 — North Carolina (NC)

01 — North Dakota (ND)

01 — Northern Nj (NJ)

02 — NYC Suburbs/Long Island (NY)

00 — Ohio (OH)

00 — Oklahoma (OK)

17 — Oxnard-Thousand Oaks-Ventura (CA)

01 — Portland (OR)

03 — Poughkpsie/N NYC Suburbs (NY)

20 — Puerto Rico (PR)

04 — Queens (NY)

61 — Redding (CA)

75 — Rest of California (CA)

99 — Rest of Florida (FL)

99 — Rest of Georgia (GA)

99 — Rest of Illinois (IL)

99 — Rest of Louisiana (LA)

99 — Rest of Maine (ME)

99 — Rest of Maryland (MD)

99 — Rest of Massachusetts (MA)

99 — Rest of Michigan (MI)

99 — Rest of Missouri (MO)

99 — Rest of New Jersey (NJ)

99 — Rest of New York (NY)

99 — Rest of Oregon (OR)

99 — Rest of Pennsylvania (PA)

99 — Rest of Texas (TX)

99 — Rest of Washington (WA)

01 — Rhode Island (RI)

62 — Riverside-San Bernardino-Ontario (CA)

63 — Sacramento-Roseville-Folsom (CA)

64 — Salinas (CA)

72 — San Diego-Chula Vista-Carlsbad (CA)

52 — San Francisco-Oakland-Berkeley (Marin County) (CA)

05 — San Francisco-Oakland-Berkeley (San Francisco/San Mateo/Alameda/Contra Costa County) (CA)

65 — San Jose-Sunnyvale-Santa Clara (San Benito County) (CA)

09 — San Jose-Sunnyvale-Santa Clara (Santa Clara County) (CA)

73 — San Luis Obispo-Paso Robles (CA)

66 — Santa Cruz-Watsonville (CA)

74 — Santa Maria-Santa Barbara (CA)

67 — Santa Rosa-Petaluma (CA)

02 — Seattle (King County) (WA)

01 — South Carolina (SC)

02 — South Dakota (SD)

03 — Southern Maine (ME)

68 — Stockton (CA)

15 — Suburban Chicago (IL)

35 — Tennessee (TN)

09 — Utah (UT)

53 — Vallejo (CA)

50 — Vermont (VT)

00 — Virginia (VA)

50 — Virgin Islands (VI)

69 — Visalia (CA)

16 — West Virginia (WV)

00 — Wisconsin (WI)

21 — Wyoming (WY)

70 — Yuba City (CA)

Apply sequestration to Medicare's portion

Setting changes this rate by $96.19

54160 is $228.46 in an office and $132.27 in a facility at the national baseline. Use the setting that matches where the service was furnished.

54160 2026 C · National (GPCI 1.000) · Office (non-facility) · status A (Active)

Medicare calculates a national payment amount for this code and pays it separately when the service is covered.

Expected Medicare payment

$179.11

Patient / secondary: $45.69
Expected total to provider: $224.80
Allowed amount: $228.46

Assumes the Part B deductible has been met. Sequestration is applied to Medicare’s portion.

Compare a remittance

Allowed amount on remittance

Payer paid

Optional: compare allocation, not just the allowed amount.

Patient responsibility

Optional. If allowed is blank, payer paid + patient responsibility becomes the remittance allowed.

Use a commercial contract based on Medicare

Contract percentage

For commercial contracts priced as a percentage of Medicare (for example, 115%).

Checking a whole code mix? Use Contract Check.

How Localis calculated $228.46

CMS 2026 C PFS · component math available

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	2.47	1.000	2.470
Practice expense (non-facility)	4.04	1.000	4.040
Malpractice	0.33	1.000	0.330
× conversion factor $33.4009 = allowed			$228.46

54160 — 2026 C · National (GPCI 1.000) · Office (non-facility)
Allowed amount: $228.46
Medicare pays: $179.11
Patient / secondary: $45.69
Expected total to provider: $224.80

Need this programmatically?

Get the same expected amount, release, status, and citations through the free API.

View API example →

Pricing a commercial contract?

Use Contract Check for a weighted code mix instead of a single line-item multiplier.

Open Contract Check →

Checking more than one line?

Join the batch payment-review pilot for remittances and larger variance files.

Join the pilot →

Did this answer your question about this calculator?

We're building this out in the open. Tell us what you were actually trying to work out and we'll either answer you directly or build the page that does.