2.46
RVU
$83.37
$100.04
$125.06
2.46
RVU
$83.37
$100.04
$125.06
Medical billing is a field unto itself, and the Medicare Physician Fee Schedule (MPFS) forms the foundation of payment rates for nearly every medical procedure in the United States. Whether you are a healthcare administrator benchmarking fees, a physician practice setting charge amounts, or a patient trying to understand what a procedure should cost, the MPFS methodology provides the most transparent framework available. This Physician Fee Schedule Tool implements the complete CMS formula, allowing you to calculate Medicare-allowed amounts for any procedure code and estimate private payer rates as a percentage of Medicare.
The MPFS uses a three-component Relative Value Unit (RVU) system. Every procedure code (CPT code) is assigned three RVU components: Work RVUs (wRVU) reflect physician time, skill, training, and intensity required to perform the service. Practice Expense RVUs (peRVU) capture the cost of running the practice — staff, equipment, supplies, and overhead. Malpractice RVUs (mpRVU) represent the professional liability insurance costs associated with the service.
These three components are each adjusted by a Geographic Practice Cost Index (GPCI) — locality-specific factors that account for variations in wages, rents, and malpractice insurance premiums across different markets. A procedure performed in Manhattan has higher practice expense costs than the same procedure in rural Mississippi, and the GPCI adjusts accordingly. CMS publishes GPCI values for over 80 payment localities across the US.
After geographic adjustment, the sum of the three adjusted RVU components is multiplied by the Conversion Factor (CF) — a single dollar amount per RVU set annually by CMS through the budget neutrality process and any legislative updates. The 2024 conversion factor was approximately $33.89 per RVU, though this changes each January.
Private payers — commercial insurers like UnitedHealthcare, Aetna, and Blue Cross — typically negotiate rates expressed as a percentage of Medicare. Primary care and outpatient services often range from 110–130% of Medicare. Specialist procedures may be 130–200% of Medicare depending on the market, specialty, and payer-provider negotiating power. Our calculator shows 120% and 150% of Medicare as reference private payer benchmarks.
Understanding the fee schedule empowers practices to set appropriate charge masters, evaluate payer contracts, and benchmark reimbursement. For patients, comparing your EOB payment to the Medicare rate reveals whether your insurer's reimbursement is above or below market — useful information when evaluating plan networks.
The Medicare fee formula is: Fee = (wRVU × Work GPCI + peRVU × PE GPCI + mpRVU × MP GPCI) × Conversion Factor. Each RVU component is geographically adjusted by its corresponding GPCI before summing. The total adjusted RVUs are then multiplied by the conversion factor to yield the Medicare-allowed amount. Private payer estimates are derived by multiplying the Medicare fee by typical commercial contract multiples (120% and 150%).
A higher total RVU indicates a more complex, time-intensive, or resource-heavy procedure. A neurosurgical procedure may have 20+ total RVUs, while a brief office visit may have 1–2. If your calculated fee differs significantly from what you were billed or paid, check that you are using the correct CPT code's published RVU values from the CMS MPFS lookup tool, and verify the correct GPCI for your payment locality.
Inputs
Results
CPT 99213 (level 3 established patient visit) yields ~$56.94 Medicare rate. Private payers typically reimburse $68–$85 for this code.
Inputs
Results
Total knee replacement in a high-cost urban market with elevated GPCIs yields a Medicare rate near $1,298. Private payers may reimburse $1,558–$1,947.
The Medicare Physician Fee Schedule (MPFS) is the payment system used by CMS to reimburse physicians and other providers for covered services rendered to Medicare beneficiaries. It assigns a dollar value to each CPT procedure code using a relative value unit (RVU) methodology combined with geographic adjustments and an annual conversion factor.
CMS publishes the complete MPFS RVU database annually on its website (cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched). The file includes all CPT codes with their work, practice expense, and malpractice RVUs, as well as GPCI values by locality.
The Geographic Practice Cost Index (GPCI) adjusts RVUs for local cost variations. Work GPCIs reflect physician wage differentials; practice expense GPCIs reflect local costs for office space, staff, and supplies; malpractice GPCIs reflect local malpractice insurance premium variation. CMS updates GPCIs periodically based on Bureau of Labor Statistics and other data sources.
The conversion factor is a dollar amount per RVU that translates the unit-based RVU system into an actual payment amount. CMS updates it annually through the rulemaking process. Congress has sometimes passed legislation to prevent or modify scheduled cuts. The 2024 conversion factor was $33.8931 per RVU.
Private insurers negotiate rates with providers as a percentage of Medicare. Large insurer-provider contracts typically pay 110–200% of Medicare depending on specialty, market competition, and negotiating leverage. Independent physicians in competitive markets may receive closer to 100–110% of Medicare, while large hospital systems in concentrated markets may negotiate 200%+ of Medicare for certain services.
Providers typically bill at their 'charge master' rate — often 200–400% of Medicare — which serves as an opening negotiating position. Insurers pay the contracted rate (their negotiated percentage of Medicare). Uninsured patients may be billed at the full charge master rate, though hospitals are required to offer financial assistance programs and may have charity care policies.
This calculator specifically implements the US Medicare MPFS formula. Other countries have their own fee schedule systems — for example, the UK uses NHS tariffs, Canada uses provincial fee schedules, and Australia uses the Medicare Benefits Schedule (MBS). The RVU methodology has influenced other systems but the specific values and formulas differ.
Roboculator Team
The Roboculator Team explains calculations, planning tools, and practical formulas in clear language for real-life situations.
How helpful was this calculator?
Be the first to rate!
