How each Medicare amount in your report is set

Which fee schedule prices which line

Doctor's office or clinic bill

Physician fee schedule, non-facility amount, for your locality

Doctor's own bill for hospital, ER or surgery-center care

Physician fee schedule, facility amount, for your locality

Hospital's own bill for outpatient or ER care

Hospital outpatient (OPPS) national rate

Lab tests, any bill

Clinical Laboratory Fee Schedule national amount

Drugs given in an office

Part B drug payment limit per billing unit

Each line's Medicare amount is the amount for one unit multiplied by the units you enter. A line with no Medicare amount (for example a code Medicare does not cover) is shown with the reason and left out of the totals.

The physician fee schedule formula

Amount = [(work RVU × work GPCI) + (practice expense RVU × practice expense GPCI) + (malpractice RVU × malpractice GPCI)] × conversion factor, rounded to the cent.

Worked example, code 99213 in a doctor's office in the Atlanta locality: [(1.30 × 1.003) + (1.46 × 1.016) + (0.09 × 1.201)] × 33.4009 = $96.71.

The 2026 conversion factor, $33.4009, applies to clinicians who are not qualifying participants in an advanced alternative payment model. It includes a one-year 2.5% increase for 2026 under section 71202 of Public Law 119-21, which does not carry into 2027. The work GPCI floor of 1.0 that was applied in previous updates was extended through January 1, 2027 by section 6208 of the Consolidated Appropriations Act, 2026 (H.R. 7148, signed February 3, 2026).

For some imaging codes Medicare pays the lower of this amount and a cap based on the hospital outpatient rate (Deficit Reduction Act of 2005, section 5102(b)). Where CMS publishes a cap for your locality, the report uses the capped amount and says so.

Hospital outpatient and lab rates

For a hospital's own bill, each line gets the national payment rate from Addendum B of the Hospital Outpatient Prospective Payment System. Medicare adjusts about 60% of each rate by the local hospital wage index, so hospitals in high-wage areas are paid more than the national figure and hospitals in low-wage areas less. The report says this on every hospital bill.

Medicare pays nothing separately for some hospital lines, such as most supplies and many drugs, because their cost is included in the payment for the main service. The report marks these lines as packaged. It also flags lines Medicare sometimes pays inside a larger comprehensive rate.

Because packaging and multiple-procedure discounts reduce what Medicare actually pays, adding up line amounts gives a Medicare total on the high side. Any multiple in your report is therefore, if anything, understated.

Where you were treated

Medicare prices care by where it is given, not where the patient lives, so the report asks for the ZIP code of the provider. CMS assigns every ZIP code to one of 109 payment localities. About 480 ZIP codes straddle two localities; for those the report uses the locality CMS assigns to the ZIP code as a whole and names the other one.

What the report does not price

Inpatient hospital stays (Medicare pays those by diagnosis group, not by line), surgery-center facility fees, anesthesia time, ambulance trips, equipment and supplies, and dental codes. Lines with these codes appear in your report with the reason they have no Medicare amount.

Data files and release dates

Medicare publishes a new physician fee schedule each January with quarterly corrections, and new hospital outpatient, lab and drug files each quarter. Reports use Medicare's 2026 rates; checkout does not accept care dated in a later year until that year's files are loaded. Database last built 2026-09-28.

CPT codes

CPT code descriptions are copyrighted by the American Medical Association. FairBillCheck shows code numbers and its own broad category labels, never the AMA descriptions. HCPCS Level II descriptions, which CMS writes, are shown. CPT is a registered trademark of the American Medical Association.