localis

Describe a service in plain words, or type a CPT/HCPCS code.

Sign up

Medicare expected-payment calculator

Enter a billing code, the service-location ZIP and the date of service. Get the Medicare allowed amount, how it splits between Medicare and coinsurance, and the CMS evidence behind each figure.

Claim details

CPT / HCPCS code
Service location
ZIP
Locality

Leave blank for the national baseline.

Date of service
Date of service
CMS release

CMS release: 2026 D

Place of service Office (non-facility) Facility
Modifiers: None
Supplied modifier

Select a supplied modifier. Click it again to remove it.

Professional component
Technical component
Bilateral adjustment does not apply to this code (indicator 0).
Payable only if supporting documentation establishing the medical necessity of an assistant at surgery is submitted.
Payable only if supporting documentation establishing the medical necessity of an assistant at surgery is submitted.
Payable only if supporting documentation establishing the medical necessity of an assistant at surgery is submitted.
Payable only if supporting documentation establishing the medical necessity of an assistant at surgery is submitted.
Co-surgeon is not permitted for this code.
Team surgery is not permitted for this code.

Single-line modifiers only. Pricing -51? Use the MPPR calculator.

Payment answer

78494 National (Gpci 1.000) Q4 2026 release
Save
National PFS baseline
$211.09
in a doctor’s own office or clinic
Medicare share (80%)
$168.87
Sequestration (−2%)
−$3.38
Net Medicare payment
$165.49
Coinsurance (20%)
Owed by the patient or a secondary payer
$42.22
Expected total to provider
$207.71

Assumes the Part B deductible is met.

Date of service
Not supplied
Locality
National (Gpci 1.000)
Setting
Office (non-facility)
Participation
Participating provider
CMS release
Q4 2026

( Work1.16 × 1.000 + Practice exp.5.07 × 1.000 + Malpractice0.09 × 1.000 ) × Conv. factor$33.4009 = $211.09

Compare a remittance Check a remittance's allowed amount against this answer
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.
Commercial contract rate Model a contract paid as a percentage of Medicare
Your contract's % of Medicare For example, 115%.

Check a code mix · Find your percentage

More payment tools

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.

Did this page answer your question?