Fees & utilization API

Clinical Laboratory Fee Schedule

Lab codes aren't priced by the PFS formula — post-PAMA the CLFS is one national rate per code, with no locality and no facility/office split. So this response is deliberately much flatter than a rate lookup and takes no locality parameters.

Indicator L codes are priced by each MAC. CMS writes a literal 00000.00 for those, which is a placeholder rather than a price — the response returns payable: false with a reason and a null rate, never a $0.

{
  "hcpcs": "80053",
  "schedule": "clfs",
  "indicator": "N",
  "effective_date": "2026-01-01",
  "payable": true,
  "rate": 10.66,
  "qw": { "rate": 10.66, "effective_date": "2026-01-01", "differs_from_base": false },
  "release": { "schedule": "clfs", "year": 2026, "quarter": "C", "revision": 1 },
  "data_quality": "ok"
}

Carrier-priced (MAC) amounts

Status C codes have no national rate — each Medicare contractor publishes its own locality amounts. This endpoint returns the MAC-published figures we hold for a code, with the publishing file's own footnote legend and a per-schedule source URL, so every number can be traced to the contractor document it came from. Deliberately separate from /v1/rates: these are contractor amounts for a specific locality and effective period, never blended into national formula output. Current geographic coverage contains 63 publishing localities across Noridian JE/JF, First Coast JN (Florida, Puerto Rico, and the U.S. Virgin Islands), and Novitas JH (Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas). Coverage grows contractor by contractor; a 404 means "not on file in current coverage" and never implies a zero amount. Geographic filters are optional and mutually exclusive: jurisdiction=JE returns every covered locality in that jurisdiction; state=CA resolves its A/B jurisdiction; zip=90210 uses CMS's versioned ZIP-to-locality crosswalk to select the matching normalized MAC locality. A ZIP5 that spans localities is flagged and uses the crosswalk's dominant locality pending ZIP+4 override data. Florida Areas 03, 04, and 99 also include held First Coast schedules back to 2022. An exact Florida ZIP match returns those effective periods newest-first, each with its original source provenance; code pages and the coverage map continue to show only the latest schedule per locality. With zip, pass year and quarter together, or pass an as_of date, to resolve that ZIP against the crosswalk in effect for the requested period. Without a period selector, the latest ingested crosswalk is used. A substituted or reconstructed vintage is disclosed with structured data notes and data_quality: approximate. The crosswalk_release.reconstructed boolean makes the source status visible without parsing note text. Reconstruction notes include machine-readable detail.field_confidence for ZIP presence, state, MAC, locality, rural indicator, and ZIP+4 flag; the same note is present on ZIP-priced rate responses and historical specialty/practice-type pages. These selectors also filter MAC schedules: the response returns the latest held contractor file effective on or before the requested date or quarter. Without a period selector, the endpoint returns the full held schedule history for the selected locality or geography. See the exact held publishing localities on the current MAC coverage map.

curl "https://localishealth.com/v1/mac-fees/78815?zip=89101&as_of=2026-02-01" \
  -H "Authorization: Bearer sk_live_…"

{
  "code": "78815",
  "disclaimer": "MAC-published carrier-priced amounts for the listed locality and effective period — not a national Medicare rate.",
  "selection": {
    "basis": "zip", "zip": "89101", "state": "NV", "jurisdiction": "JE",
    "mac_code": "01312", "locality_code": "00", "locality_name": "NEVADA**",
    "exact_locality": true, "ambiguous_locality": false,
    "crosswalk_release": { "year": 2026, "quarter": "A" },
    "note": "The CMS ZIP-to-locality crosswalk resolved the exact MAC publishing locality."
  },
  "schedule_filter": {
    "as_of": "2026-02-01",
    "basis": "Latest held MAC schedule effective on or before as_of."
  },
  "note_legend": { "noridian": { "#": "Amount applies when the service is performed in a facility setting.", "C": "The payment for the technical component is capped at the OPPS amount." } },
  "count": 1,
  "schedules": [
    {
      "contractor": "noridian",
      "jurisdiction": "JE",
      "locality": "Nevada, Area 00",
      "state": "NV",
      "mac_code": "01312",
      "locality_code": "00",
      "effective_date": "2026-01-01",
      "source_url": "https://med.noridianmedicare.com/documents/d/jeb/…",
      "source_file": "nevada-area-00-january-2026….xlsx",
      "source_sha256": "…64 hexadecimal characters…",
      "retrieved_at": "2026-08-06T12:00:00+00:00",
      "fees": [
        { "modifier": "", "note": "C", "par_amount": "1571.27", "non_par_amount": "1492.71", "limiting_charge": "1716.62" },
        { "modifier": "TC", "note": "C", "par_amount": "1462.36", "non_par_amount": "1389.24", "limiting_charge": "1597.63" }
      ]
    }
  ]
}

Bulk MAC fee lookup

Look up several carrier-priced codes against one shared MAC geography and schedule period. A code with no contractor amount on file stays inside the 200 response with an empty schedules array and a message; it is never treated as zero.

curl -X POST https://localishealth.com/v1/mac-fees/bulk \
  -H "Authorization: Bearer sk_live_…" \
  -H "Content-Type: application/json" \
  -d '{"codes": ["78815", "0054T"], "zip": "89101", "as_of": "2026-02-01"}'

{
  "disclaimer": "MAC-published carrier-priced amounts for the listed locality and effective period — not a national Medicare rate.",
  "selection": { "basis": "zip", "zip": "89101", "state": "NV", "jurisdiction": "JE", … },
  "schedule_filter": { "as_of": "2026-02-01", "basis": "Latest held MAC schedule effective on or before as_of." },
  "note_legend": { "noridian": { "#": "Amount applies when the service is performed in a facility setting.", "C": "The payment for the technical component is capped at the OPPS amount." } },
  "count": 2,
  "results": [
    { "code": "78815", "count": 1, "schedules": [ { "contractor": "noridian", "effective_date": "2026-01-01", "fees": [ … ] } ] },
    { "code": "0054T", "count": 0, "message": "MAC-published amount for 0054T: not on file as of 2026-02-01 in held coverage.", "schedules": [] }
  ]
}

MAC fee-schedule directory

Which MAC-published fee schedules Localis currently holds, without requiring an hcpcs — the discovery endpoint for the geographic coverage behind the code-scoped MAC fee lookup. One row per publishing locality currently in force, with its own file provenance and how many codes it prices.

curl "https://localishealth.com/v1/mac-fees/schedules?jurisdiction=JE" \
  -H "Authorization: Bearer sk_live_…"

{
  "count": 1,
  "schedules": [
    {
      "contractor": "noridian",
      "jurisdiction": "JE",
      "locality": "Nevada, Area 00",
      "state": "NV",
      "mac_code": "01112",
      "locality_code": "00",
      "effective_date": "2026-01-01",
      "code_count": 412,
      "source_url": "https://med.noridianmedicare.com/documents/d/jeb/nevada-area-00",
      "source_file": "noridian-je-nevada-area-00-january-2026.xlsx",
      "source_sha256": "…",
      "retrieved_at": "2026-01-05T00:00:00+00:00"
    }
  ]
}

Omitting both jurisdiction and state lists every held schedule. code_count is the number of HCPCS/modifier rows on that schedule — the fee amounts themselves come from the code-scoped lookup, not this directory.

Code utilization benchmark

How a code is actually billed in Original Medicare (FFS), nationally, from CMS's annual utilization data: its ranking across all billed codes, the leading rendering-provider specialty groups by share of observed services, and the Office (non-facility) versus facility split as CMS published it. Every response is stamped with the calendar-year vintage (data_year, e.g. CY2024) — a different CMS dataset and publication cycle than the fee-schedule releases. Cells observed from fewer than min_providers distinct providers are suppressed; a code with nothing publishable returns 404, never an implied zero.

curl https://localishealth.com/v1/utilization/codes/99213 \
  -H "Authorization: Bearer sk_live_…"

{
  "code": "99213",
  "data_year": 2024,
  "scope": "Original Medicare (FFS), national",
  "ranking": { "rank": 2, "ranked_out_of": 6210, "beneficiaries": 21000000, "services": 69000000, "allowed_dollars": 5800000000, "year": 2024 },
  "specialty_shares": [
    { "specialty_group": "Family Medicine", "share_of_services": 0.31, "provider_cnt": 98211 },
    { "specialty_group": "Internal Medicine", "share_of_services": 0.24, "provider_cnt": 76544 }
  ],
  "setting_shares": { "office_non_facility": 0.87, "facility": 0.13 },
  "min_providers": 30,
  "notes": [ "The setting split is Office (non-facility) versus facility exactly as CMS published it; it identifies no exact place of service.", … ]
}

Utilization trend

A code's national billing volume by calendar year, oldest first — how far back the ranking vintages go, not a fixed window. This reads the ranking series rather than the benchmark cells, because the ranking is the only utilization data that spans many years; it's national by construction, so there are no geography or specialty parameters.

A year the code wasn't ranked is omitted rather than reported as zero — it means the code wasn't billed enough to earn a rank that year, which is a different claim from nobody billing it.

{
  "code": "99213",
  "scope": "Original Medicare (FFS), national",
  "count": 12,
  "first_year": 2013,
  "last_year": 2024,
  "trend": [
    { "year": 2013, "rank": 2, "ranked_out_of": 6104, "services": 62000000,
      "allowed_dollars": 5100000000, "beneficiary_records": 19000000 },
    { "year": 2014, "rank": 2, "ranked_out_of": 6210, "services": 64000000,
      "allowed_dollars": 5300000000, "beneficiary_records": 19600000,
      "change_from_previous": { "rank": 0, "services_percent": 3.23, "allowed_dollars_percent": 3.92 } }
  ],
  "notes": ["…"]
}

Specialty cohort directory

The specialty slugs that map to an observed CMS rendering-provider cohort, with the exact specialty groups each cohort comprises. Slugs without a reviewed mapping are omitted rather than guessed.

{
  "count": 24,
  "specialties": [
    { "slug": "cardiology", "label": "Cardiology", "specialty_groups": ["Cardiology"] },
    { "slug": "primary-care", "label": "Primary Care", "specialty_groups": ["Family Medicine", "Internal Medicine"] }
  ]
}

Specialty utilization benchmark

A specialty cohort's observed Medicare FFS utilization: top codes by allowed dollars and by services, office E/M level curves, and how much of the observed activity the current PFS release can price — with that release echoed on the priced figures. Shares are of the cohort's whole observed total; code cells under the minimum-provider floor are suppressed but still count in every denominator, so nothing shown inflates.

curl https://localishealth.com/v1/utilization/specialties/primary-care \
  -H "Authorization: Bearer sk_live_…"

{
  "slug": "primary-care",
  "label": "Primary Care",
  "data_year": 2024,
  "scope": "Original Medicare (FFS), national",
  "specialty_groups": ["Family Medicine", "Internal Medicine"],
  "top_codes_by_allowed": [
    { "code": "99214", "service_cnt": 61000000, "allowed_total": 7400000000, "share_of_allowed": 0.22, "share_of_services": 0.18, "curated": true }
  ],
  "top_codes_by_services": [ … ],
  "watchlist_starters": [ … ],
  "priceable": { "release": { "year": 2026, "quarter": "A" }, "allowed_share": 0.91, "service_share": 0.88 },
  "em_curves": {
    "established_office": {
      "setting": "office_non_facility", "provider_cnt": 210344, "service_cnt": 98000000,
      "level_shares": { "99211": 0.02, "99212": 0.06, "99213": 0.41, "99214": 0.44, "99215": 0.07 },
      "member_contributions": { "Family Medicine": 0.55, "Internal Medicine": 0.45 },
      "methodology_version": "em-cohorts-v1", "geography": "national"
    },
    "new_office": { … }
  },
  "min_providers": 30,
  "notes": [ … ]
}