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.

99425 2026 C · National (GPCI 1.000) A Active

Non-facility

Facility

Allowed amount

$61.46

in a doctor’s own office or clinic

Medicare payment: $49.17
Sequestration (−2%): −$0.98
Net Medicare payment: $48.19
Patient / secondary: $12.29
Expected total to provider: $60.48

Patient / secondary and expected total to provider assume the Part B annual deductible is already met. If it isn't, the patient owes more than the amount shown here.

Locality-adjusted Physician Fee Schedule pricing

Formula

(work_rvu × work_gpci + pe_rvu × pe_gpci + mp_rvu × mp_gpci) × conversion_factor

RVU × GPCI components of this amount
Component	RVU	× GPCI	= Adjusted
Work	1.00	× 1.000	1.0000
Practice expense	0.77	× 1.000	0.7700
Malpractice	0.07	× 1.000	0.0700
Sum of adjusted RVUs			1.8400
× 33.4009 conversion factor			$61.46

Citations

Physician relative value file (PPRRVU) PPRRVU2026_Jul_nonQPP.csv in rvu26c-updated-06-30-2026.zip (row 13,045)

hcpcs (col 1)

99425

status_code (col 4)

A

work_rvu (col 6)

1

pe_rvu_nonfacility (col 7)

0.77

pe_rvu_facility (col 9)

0.25

mp_rvu (col 11)

0.07
Physician relative value file (PPRRVU) PPRRVU2026_Jul_nonQPP.csv in rvu26c-updated-06-30-2026.zip (row 11)

conversion_factor (col 26)

33.4009

CPT / HCPCS code

Modifiers

Code does not support a professional/technical split (PCTC indicator 0).

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.

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.

ZIP

Locality

Preferred: resolves the Medicare payment locality for this line.

Release

Date

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

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 →

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

Commercial payer contracts usually price off the Medicare amount above ("BCBS pays 115% of Medicare"). Enter your contract's percentage to see what 99425 pays at that rate.

Your contract's % of Medicare

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

Checking a whole code mix? Use Contract Check.

We want to build this: store your multipliers once, and every code page shows your rate instead of Medicare's. Tell us if you'd use it →

See how to find your contract's actual percentage.

How Localis calculated $61.46

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	1.00	1.000	1.000
Practice expense (non-facility)	0.77	1.000	0.770
Malpractice	0.07	1.000	0.070
× conversion factor $33.4009 = allowed			$61.46

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.