{
 "table_version": "2026-09-09.1",
 "generated": "2026-09-10",
 "rows": 274,
 "source_data_files": [
  {
   "file": "data/prices.json",
   "rows": 117,
   "assembled": "2026-09-08"
  },
  {
   "file": "data/prices-additions-2026-09-09.json",
   "rows": 157,
   "assembled": "2026-09-09",
   "source_files": {
    "pfs_zip_url": "https://www.cms.gov/files/zip/rvu26c-updated-06-30-2026.zip",
    "pfs_csv": "PPRRVU2026_Jul_nonQPP.csv",
    "pfs_csv_sha256": "b7d197e73211ef6854c213c267d5fa9dec8df995db8e1ee7d44c0556ad7cee21",
    "clfs_zip_url": "https://www.cms.gov/files/zip/26clabq3.zip",
    "clfs_csv": "PUF_CLFS_CY2026_Q3V1.csv",
    "clfs_csv_sha256": "f5a090789c40fe791b478a735c7cf5399e86726adc788f11829435cb0ca4d7d5"
   }
  }
 ],
 "license": "The federal figures in this table are U.S. Government works and are in the public domain. Our additions — the plain-language labels, the synonyms, the coverage statements, the combination rules and this arrangement — are dedicated to the public domain by Precision Federal LLC under CC0 1.0. Take it, fork it, correct it. Attribution is welcome and not required.",
 "how_to_cite": "Waypoint Ledger price table, version 2026-09-09.1, Precision Federal LLC, https://waypoint-ledger.pages.dev/data/price-table.csv. Every row carries the federal source it came from; cite that source for the figure and this table for the arrangement.",
 "readme": "Waypoint Ledger price table. EVERY figure here was read directly out of the cited federal source file, or is the explicit product of two such figures with the formula printed on the face of the number. Nothing is estimated, inflated, interpolated or recalled. If a line item has no published figure it is ABSENT from this file and appears in the app as unpriced — see GAPS.md. Adding a number here without opening the source and reading it is the one thing that breaks this product.",
 "confidence_legend": {
  "VERIFIED": "Read in the cited source document during collection.",
  "DERIVED": "Computed from figures read in the cited source, using the source's own formula, with the inputs stated in the coverage statement so a stranger can redo the arithmetic. CMS publishes relative value units and a conversion factor, not a dollar column, so every physician fee schedule figure is necessarily DERIVED. Calling it VERIFIED would be a small lie.",
  "REPORTED": "Read in a secondary source that cites the primary. NO FIGURE IN THIS FILE CARRIES THIS LABEL."
 },
 "basis_legend": {
  "allowed_amount": "The Medicare-approved price: program payment plus the beneficiary's share. CMS fee schedules. Under CMS rules labs and imaging are SEPARATELY billable, so they can legitimately be added to a visit.",
  "payment": "What all payers actually paid, combined. MEPS household survey. Under MEPS rules, labs and imaging are BUNDLED into the visit's total and must NOT be added on top of it.",
  "out_of_pocket": "What the person paid themselves.",
  "charge": "What the provider billed. Almost never what an insured person pays; it is what an uninsured person is billed against.",
  "facility_cost": "What it cost the HOSPITAL to produce the service — wages, supplies, utilities. AHRQ's HCUP reports. This is a sixth kind of number and is none of the five above; it was given its own label rather than forced into one that would misdescribe it.",
  "total_expenditure": "Spending across a whole year from all sources, per person.",
  "wage": "Earnings. An input to a lost-time calculation, never a price.",
  "ratio": "A unitless conversion factor. Carries no dollar value by design."
 },
 "combination_rules": {
  "_why": "Two figures can both be true and still be wrong when added. These rules are machine-readable because a rule written only in prose is not a guard — it is a wish.",
  "summable": "Only items with summable=true may enter an itemized ledger total. Everything else is an alternative view, shown beside the total and never inside it.",
  "mutually_exclusive_with": "Ids that must never appear in the same sum as this item. '__ALL_PER_EVENT_LINES__' means the figure is a whole-year total that already contains every visit, test and scan.",
  "bundles_ancillaries": "true means the figure ALREADY INCLUDES labs and imaging ordered during the event, so those must not be added on top. THIS DIFFERS BY SOURCE: MEPS and HCUP bundle them; CMS fee schedules bill them separately. There is no single global rule for whether a lab can be added to a visit, and assuming one is how double counting happens.",
  "evaluation_order": [
   "🔴 THE ORDER MATTERS AND IS NOT OPTIONAL. Applying these checks in a different order gives wrong answers — an exclusion test run before the summable filter blocks BOTH sides of a conflict symmetrically and silently zeroes a legitimate line.",
   "STEP 1 — drop every item with summable=false. These are alternative views; they are rendered beside the total, never inside it.",
   "STEP 2 — among the lines that SURVIVED step 1, block any line named in another survivor's mutually_exclusive_with, and block any line whose own list names '__ALL_PER_EVENT_LINES__'.",
   "STEP 3 — if more than one basis remains, refuse to produce a total at all. Do not sum, do not average, do not silently pick one.",
   "STEP 4 — if any surviving line has bundles_ancillaries=true, refuse to add any lab or imaging line to it; that figure already contains them.",
   "STEP 5 — only now, sum."
  ],
  "guard_must_be_proven": "A guard that has never been shown to fire is not a guard. Before shipping, plant each violation above and confirm the refusal actually happens — an all-clear from a check that cannot detect the failure is worse than no check, because it reads as safety.",
  "never_mix_bases": "Never sum across bases. Never average across bases. A single ER visit appears here as $544.54 (CMS allowed), $1,048 (MEPS payment) and $750 (HCUP facility cost) — three answers to three different questions, not three estimates of one.",
  "mean_and_median": "A mean and a median of the same population are two views of one distribution, never two costs. Never sum them.",
  "legitimate_addition_that_looks_like_double_counting": "A CMS hospital facility fee and a CMS physician fee for the SAME encounter ARE two separate real bills and DO add: $426.30 + $118.24 = $544.54 for an ER visit; $136.02 + $84.50 = $220.52 for a hospital-clinic visit. That addition is correct and is the honest way to price an encounter."
 },
 "prohibited_derivations": [
  {
   "forbidden": "$750 divided by 0.21 = $3,571 as a national average ER charge",
   "why": "Arithmetically invalid — the mean of hospital-level cost-to-charge ratios is not the ratio of national means. No source publishes this number. Recorded here so a later pass cannot rediscover it innocently; it is tempting because it would make an excellent headline."
  },
  {
   "forbidden": "13.6 percent multiplied by $6,765 presented as a published average out-of-pocket figure",
   "why": "That product is our derivation, not a MEPS estimate, and the underlying share is regressive."
  },
  {
   "forbidden": "$4,098 multiplied by 5 as a five-year long COVID cost",
   "why": "The one published five-year figure is $7,124, not $20,490, because it prices at different rates and excludes physician fees, labs, imaging readings and pharmacy — most of an odyssey. The two cannot be reconciled and neither can be scaled into the other."
  },
  {
   "forbidden": "Dividing any national aggregate by a patient count to price one person",
   "why": "National totals for labor-force exit and absenteeism measure population phenomena, not individuals."
  },
  {
   "forbidden": "Dividing an annual prescription figure by an assumed number of fills",
   "why": "MEPS stopped publishing per-fill figures around 2006; the modern figures are annual per user."
  },
  {
   "forbidden": "Inflating any dated figure forward to today's dollars",
   "why": "The moment we adjust it, the number is ours rather than the government's. We show the published figure with its year on its face and say plainly that it is stale."
  }
 ],
 "audit": {
  "generated": "2026-09-09",
  "rows": 274,
  "pass": 274,
  "fail": 0,
  "unverified": 0,
  "alternates": 80,
  "alternates_pass": 80,
  "alternates_fail": 0,
  "alternates_unverified": 0,
  "localities": {
   "rows": 52,
   "figures": 5668,
   "pass": 5668,
   "fail": 0,
   "status": "PASS",
   "formula": "(work_rvu*pw_gpci + pe_nonfacility_rvu*pe_gpci + mp_rvu*mp_gpci) * 33.4009",
   "conversion_factor": 33.4009,
   "evidence": "5668 figures re-derived from PPRRVU2026_Jul_nonQPP.csv and GPCI2026.csv at the cent"
  },
  "version_line": "274 rows · 274 reproduce · 80 CY2024 companion figures · 134 hospital-setting figures · 5,668 locality figures · audited 2026-09-09",
  "sources": {
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    "file": "PUF_CLFS_CY2026_Q3V1.csv"
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   },
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   },
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 },
 "items": [
  {
   "id": "cms-99213",
   "label": "Doctor's office visit, established patient, low complexity",
   "plain_language_synonyms": [
    "saw my regular doctor",
    "quick follow-up",
    "short doctor visit",
    "check-in with my doctor",
    "follow-up appointment",
    "routine visit"
   ],
   "value_usd": 95.19,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A follow-up visit with a doctor you have seen before, for a straightforward problem. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 2.85 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $189.25 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 99213",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 189.25,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 85.37,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "hospital_outpatient_facility_fee_usd": 136.02,
    "hospital_outpatient_facility_fee_source": "CMS, January 2026 Hospital Outpatient Prospective Payment System Addendum B",
    "_opps_note": "If this happened inside a hospital-owned clinic or hospital department rather than a freestanding office, the hospital bills THIS fee in addition to the clinician's fee. Long COVID clinics are disproportionately hospital-based, so this is often the applicable path, not the exception.",
    "hospital_outpatient_minimum_beneficiary_copay_usd": 27.21,
    "facility_setting_physician_payment_usd": 57.45,
    "facility_setting_total_rvu": 1.72,
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 1.72 facility total RVUs x $33.4009 = $57.45. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=99213, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 64778139.1,
    "cy2024_rendering_providers": 631995,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_component": "FACILITY TOTAL on the unmodified line"
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-99213",
    "status": "PASS",
    "value_usd": 95.19,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 189.25,
      "evidence": "Avg_Sbmtd_Chrg = $189.25 on the National office row for 99213, alongside 64,778,139 services from 631,995 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 85.37,
      "evidence": "Avg_Mdcr_Alowd_Amt = $85.37 on the National office row for 99213, alongside 64,778,139 services from 631,995 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 57.45,
      "evidence": "1.72 facility total RVUs on the unmodified line for 99213 x $33.4009 = $57.45"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 99213",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "2.85 total non-facility RVUs x $33.4009 = $95.19",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-99214",
   "label": "Doctor's office visit, established patient, moderate complexity",
   "plain_language_synonyms": [
    "saw my doctor",
    "went to the doctor",
    "doctor visit",
    "office visit",
    "saw my primary care doctor",
    "my GP",
    "family doctor",
    "regular appointment",
    "follow-up with my doctor"
   ],
   "value_usd": 135.61,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The workhorse visit of a diagnostic odyssey: a follow-up with a doctor who already knows you, for a problem that takes real thinking — reviewing results, adjusting a plan, deciding what to test next. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 4.06 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $276.45 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 99214",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 276.45,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 119.71,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "hospital_outpatient_facility_fee_usd": 136.02,
    "hospital_outpatient_facility_fee_source": "CMS, January 2026 Hospital Outpatient Prospective Payment System Addendum B",
    "_opps_note": "If this happened inside a hospital-owned clinic or hospital department rather than a freestanding office, the hospital bills THIS fee in addition to the clinician's fee. Long COVID clinics are disproportionately hospital-based, so this is often the applicable path, not the exception.",
    "hospital_outpatient_minimum_beneficiary_copay_usd": 27.21,
    "facility_setting_physician_payment_usd": 84.5,
    "facility_setting_total_rvu": 2.53,
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 2.53 facility total RVUs x $33.4009 = $84.50. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=99214, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 95439230.1,
    "cy2024_rendering_providers": 641674,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_component": "FACILITY TOTAL on the unmodified line"
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-99214",
    "status": "PASS",
    "value_usd": 135.61,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 276.45,
      "evidence": "Avg_Sbmtd_Chrg = $276.45 on the National office row for 99214, alongside 95,439,230 services from 641,674 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 119.71,
      "evidence": "Avg_Mdcr_Alowd_Amt = $119.71 on the National office row for 99214, alongside 95,439,230 services from 641,674 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 84.5,
      "evidence": "2.53 facility total RVUs on the unmodified line for 99214 x $33.4009 = $84.50"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 99214",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "4.06 total non-facility RVUs x $33.4009 = $135.61",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-99215",
   "label": "Doctor's office visit, established patient, high complexity",
   "plain_language_synonyms": [
    "long visit with my doctor",
    "complicated appointment",
    "in-depth visit",
    "hour with my doctor"
   ],
   "value_usd": 192.39,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A long, complicated follow-up visit with a doctor who already knows you. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 5.76 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $406.36 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 99215",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 406.36,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 169.67,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "hospital_outpatient_facility_fee_usd": 136.02,
    "hospital_outpatient_facility_fee_source": "CMS, January 2026 Hospital Outpatient Prospective Payment System Addendum B",
    "_opps_note": "If this happened inside a hospital-owned clinic or hospital department rather than a freestanding office, the hospital bills THIS fee in addition to the clinician's fee. Long COVID clinics are disproportionately hospital-based, so this is often the applicable path, not the exception.",
    "hospital_outpatient_minimum_beneficiary_copay_usd": 27.21,
    "facility_setting_physician_payment_usd": 125.59,
    "facility_setting_total_rvu": 3.76,
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 3.76 facility total RVUs x $33.4009 = $125.59. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=99215, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 10326407,
    "cy2024_rendering_providers": 340863,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_component": "FACILITY TOTAL on the unmodified line"
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-99215",
    "status": "PASS",
    "value_usd": 192.39,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 406.36,
      "evidence": "Avg_Sbmtd_Chrg = $406.36 on the National office row for 99215, alongside 10,326,407 services from 340,863 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 169.67,
      "evidence": "Avg_Mdcr_Alowd_Amt = $169.67 on the National office row for 99215, alongside 10,326,407 services from 340,863 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 125.59,
      "evidence": "3.76 facility total RVUs on the unmodified line for 99215 x $33.4009 = $125.59"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 99215",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "5.76 total non-facility RVUs x $33.4009 = $192.39",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-99203",
   "label": "First visit with a new doctor, lower complexity",
   "plain_language_synonyms": [
    "first time seeing a new doctor",
    "new patient visit",
    "new doctor"
   ],
   "value_usd": 117.57,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A first appointment with a doctor who has never seen you before, for a more straightforward problem. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.52 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $267.25 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 99203",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 267.25,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 105.33,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "hospital_outpatient_facility_fee_usd": 136.02,
    "hospital_outpatient_facility_fee_source": "CMS, January 2026 Hospital Outpatient Prospective Payment System Addendum B",
    "_opps_note": "If this happened inside a hospital-owned clinic or hospital department rather than a freestanding office, the hospital bills THIS fee in addition to the clinician's fee. Long COVID clinics are disproportionately hospital-based, so this is often the applicable path, not the exception.",
    "hospital_outpatient_minimum_beneficiary_copay_usd": 27.21,
    "facility_setting_physician_payment_usd": 71.48,
    "facility_setting_total_rvu": 2.14,
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 2.14 facility total RVUs x $33.4009 = $71.48. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=99203, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 8070604,
    "cy2024_rendering_providers": 388139,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_component": "FACILITY TOTAL on the unmodified line"
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-99203",
    "status": "PASS",
    "value_usd": 117.57,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 267.25,
      "evidence": "Avg_Sbmtd_Chrg = $267.25 on the National office row for 99203, alongside 8,070,604 services from 388,139 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 105.33,
      "evidence": "Avg_Mdcr_Alowd_Amt = $105.33 on the National office row for 99203, alongside 8,070,604 services from 388,139 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 71.48,
      "evidence": "2.14 facility total RVUs on the unmodified line for 99203 x $33.4009 = $71.48"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 99203",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.52 total non-facility RVUs x $33.4009 = $117.57",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-99204",
   "label": "First visit with a new specialist",
   "plain_language_synonyms": [
    "saw a specialist",
    "specialist visit",
    "referred to a specialist",
    "first visit with a specialist",
    "saw a pulmonologist",
    "saw a cardiologist",
    "saw a neurologist",
    "saw a rheumatologist",
    "saw an infectious disease doctor",
    "lung doctor",
    "heart doctor",
    "brain doctor",
    "new specialist"
   ],
   "value_usd": 177.36,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The code most first-time specialist consults are billed under. Pulmonology, cardiology, neurology, rheumatology and infectious disease all use the same new-patient ladder, so one rate prices any of those first visits. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 5.31 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $410.82 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one. A note on why this comes from Medicare and not from the household survey that anchors the rest of this tool: MEPS, the survey that measures what Americans actually pay, breaks out only eight named specialties and pools pulmonology and rheumatology into an 'all other' bucket spanning about 25 specialties, while neurology and infectious disease are not named anywhere in it. Using that bucket average as a pulmonology price would mean averaging a rheumatology consult with an oncology consult and calling the result pulmonology. We would rather switch to a Medicare price and tell you we switched.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 99204",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 410.82,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 160.28,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "hospital_outpatient_facility_fee_usd": 136.02,
    "hospital_outpatient_facility_fee_source": "CMS, January 2026 Hospital Outpatient Prospective Payment System Addendum B",
    "_opps_note": "If this happened inside a hospital-owned clinic or hospital department rather than a freestanding office, the hospital bills THIS fee in addition to the clinician's fee. Long COVID clinics are disproportionately hospital-based, so this is often the applicable path, not the exception.",
    "hospital_outpatient_minimum_beneficiary_copay_usd": 27.21,
    "facility_setting_physician_payment_usd": 116.9,
    "facility_setting_total_rvu": 3.5,
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 3.50 facility total RVUs x $33.4009 = $116.90. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=99204, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 11402207,
    "cy2024_rendering_providers": 459358,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_component": "FACILITY TOTAL on the unmodified line"
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-99204",
    "status": "PASS",
    "value_usd": 177.36,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 410.82,
      "evidence": "Avg_Sbmtd_Chrg = $410.82 on the National office row for 99204, alongside 11,402,207 services from 459,358 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 160.28,
      "evidence": "Avg_Mdcr_Alowd_Amt = $160.28 on the National office row for 99204, alongside 11,402,207 services from 459,358 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 116.9,
      "evidence": "3.50 facility total RVUs on the unmodified line for 99204 x $33.4009 = $116.90"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 99204",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "5.31 total non-facility RVUs x $33.4009 = $177.36",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-99205",
   "label": "First visit with a new specialist, highest complexity",
   "plain_language_synonyms": [
    "long first visit with a specialist",
    "post-covid clinic intake",
    "long covid clinic first visit",
    "comprehensive evaluation",
    "new patient long appointment"
   ],
   "value_usd": 236.81,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The highest-complexity first visit with a new doctor — common for a first specialty evaluation of long COVID, where a clinician reads through a year or more of prior records. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 7.09 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $560.92 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one. There is no CPT code for a multidisciplinary long COVID clinic program. Those programs bill ordinary new-patient and established-patient visits, so any premium such a program charges is invisible in CMS data.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 99205",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 560.92,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 213.67,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "hospital_outpatient_facility_fee_usd": 136.02,
    "hospital_outpatient_facility_fee_source": "CMS, January 2026 Hospital Outpatient Prospective Payment System Addendum B",
    "_opps_note": "If this happened inside a hospital-owned clinic or hospital department rather than a freestanding office, the hospital bills THIS fee in addition to the clinician's fee. Long COVID clinics are disproportionately hospital-based, so this is often the applicable path, not the exception.",
    "hospital_outpatient_minimum_beneficiary_copay_usd": 27.21,
    "facility_setting_physician_payment_usd": 160.32,
    "facility_setting_total_rvu": 4.8,
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 4.80 facility total RVUs x $33.4009 = $160.32. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=99205, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 2338334,
    "cy2024_rendering_providers": 198901,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_component": "FACILITY TOTAL on the unmodified line"
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-99205",
    "status": "PASS",
    "value_usd": 236.81,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 560.92,
      "evidence": "Avg_Sbmtd_Chrg = $560.92 on the National office row for 99205, alongside 2,338,334 services from 198,901 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 213.67,
      "evidence": "Avg_Mdcr_Alowd_Amt = $213.67 on the National office row for 99205, alongside 2,338,334 services from 198,901 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 160.32,
      "evidence": "4.80 facility total RVUs on the unmodified line for 99205 x $33.4009 = $160.32"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 99205",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "7.09 total non-facility RVUs x $33.4009 = $236.81",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-99212",
   "label": "Very short office visit, established patient",
   "plain_language_synonyms": [
    "quick check",
    "brief visit",
    "ten minute visit",
    "nurse visit"
   ],
   "value_usd": 59.45,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A brief follow-up with a doctor you have seen before, for a simple issue. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.78 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $118.03 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 99212",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 118.03,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 53.59,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "facility_setting_physician_payment_usd": 31.06,
    "facility_setting_total_rvu": 0.93,
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 0.93 facility total RVUs x $33.4009 = $31.06. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=99212, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 6241712.6,
    "cy2024_rendering_providers": 319826,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_component": "FACILITY TOTAL on the unmodified line"
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-99212",
    "status": "PASS",
    "value_usd": 59.45,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 118.03,
      "evidence": "Avg_Sbmtd_Chrg = $118.03 on the National office row for 99212, alongside 6,241,712 services from 319,826 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 53.59,
      "evidence": "Avg_Mdcr_Alowd_Amt = $53.59 on the National office row for 99212, alongside 6,241,712 services from 319,826 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 31.06,
      "evidence": "0.93 facility total RVUs on the unmodified line for 99212 x $33.4009 = $31.06"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 99212",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.78 total non-facility RVUs x $33.4009 = $59.45",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-g0463-hospital-clinic-fee",
   "label": "Hospital's own fee for a clinic visit (billed on top of the doctor's fee)",
   "plain_language_synonyms": [
    "facility fee",
    "hospital clinic fee",
    "second bill from the hospital",
    "clinic charge",
    "the hospital billed me separately",
    "two bills for one visit"
   ],
   "value_usd": 136.02,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national unadjusted (before each hospital's wage-index adjustment)",
   "population": "Medicare beneficiaries seen in a hospital-owned (provider-based) outpatient clinic",
   "coverage_statement": "This is the fee the HOSPITAL charges for hosting the visit, and it is billed IN ADDITION to the doctor's own fee — which is also reduced when the visit happens in a hospital clinic. The arithmetic on a low-complexity follow-up, CPT 99213: $57.45 to the clinician plus $136.02 to the hospital is $193.47, against $95.19 for the exact same visit in a freestanding private office. The service is identical; the address changed the price. This matters more for long COVID than for almost any other condition, because long COVID clinics are disproportionately hospital-based and academic, so the two-bill structure is the norm rather than the exception. A Medicare patient's minimum copay on the hospital half is $27.21. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. This is a national unadjusted rate; every hospital's actual payment is adjusted by its own local wage index, and in some markets that moves it by more than 30 percent. It does not apply at an independent physician's office at all.",
   "source_title": "CMS, January 2026 Hospital Outpatient Prospective Payment System Addendum B",
   "source_url": "https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient-pps/quarterly-addenda-updates/january-2026-addendum-b",
   "confidence": "VERIFIED",
   "code": "HCPCS G0463 (APC 5012)",
   "alternates": {
    "hospital_outpatient_minimum_beneficiary_copay_usd": 27.21
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-g0463-hospital-clinic-fee",
    "status": "PASS",
    "value_usd": 136.02,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "HCPCS G0463 (APC 5012)",
    "loinc": null,
    "check": "OPPS Addendum B lookup",
    "evidence": "G0463 pays $136.02 under APC 5012, minimum unadjusted copayment $27.21",
    "source_url": "https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient-pps/quarterly-addenda-updates/january-2026-addendum-b",
    "source_key": "oppsb",
    "extras": []
   }
  },
  {
   "id": "cms-ed-99284-complete",
   "label": "Emergency room visit, moderate complexity — the whole encounter",
   "plain_language_synonyms": [
    "went to the ER",
    "emergency room",
    "ER visit",
    "emergency department",
    "went to emergency",
    "taken to the ER",
    "ended up in the ER",
    "went to the emergency room with chest pain"
   ],
   "value_usd": 544.54,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [
    "cms-ed-99284-physician-only",
    "cms-ed-99284-facility-only"
   ],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national unadjusted",
   "population": "Medicare fee-for-service beneficiaries seen in a hospital emergency department",
   "coverage_statement": "An emergency room visit generates TWO separate bills and most cost tools show only one of them. This figure is both: the hospital's fee of $426.30 plus the emergency physician's fee of $118.24. Each half is a separately published CMS rate; the addition is ours and is stated here so you can check it. Showing only the physician's half — which is what a fee-schedule lookup gives you — understates an ER visit by about 78 percent. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. What this figure EXCLUDES: everything ordered during the visit. Blood work, imaging, and EKGs are billed on top of this. If your visit was coded at a different level the hospital half changes to $278.89 (lower complexity) or $608.43 (highest). A Medicare patient's minimum copay on the hospital half is $85.26. The average CHARGE submitted for just the physician half in 2024 was $788.07 — and the hospital's charge, which is the larger of the two, is not published in this dataset at all, so no complete charge figure for an ER visit exists here.",
   "source_title": "CMS, January 2026 Hospital Outpatient Prospective Payment System Addendum B; CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient-pps/quarterly-addenda-updates/january-2026-addendum-b",
   "confidence": "DERIVED",
   "code": "CPT 99284 (APC 5024)",
   "alternates": {
    "hospital_facility_fee_usd": 426.3,
    "physician_fee_usd": 118.24,
    "hospital_outpatient_minimum_beneficiary_copay_usd": 85.26,
    "level_3_facility_fee_usd": 278.89,
    "level_5_facility_fee_usd": 608.43,
    "cy2024_physician_component_average_submitted_charge_usd": 788.07,
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=99284, Place_Of_Srvc=F",
    "cy2024_place_of_service": "F — facility setting (this is the place of service an emergency department bills under)",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_total_services": 4531103,
    "cy2024_rendering_providers": 117351,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "cy2024_average_allowed_usd": 114.81,
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "_charge_note": "CHARGE basis, CY2024, facility place of service — the emergency physician’s own submitted charge, averaged over 4,531,103 services from 117,351 providers. CMS publishes no submitted-charge figure for the hospital’s side of an ED encounter, which is the larger half of the bill.",
    "_allowed_note": "ALLOWED basis, CY2024, same file and same facility row: Medicare allowed $114.81 on average for the emergency physician’s side of these 4,531,103 visits. It is not the hospital’s payment, and it is never added to the charge above."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-ed-99284-complete",
    "status": "PASS",
    "value_usd": 544.54,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_physician_component_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 788.07,
      "evidence": "Avg_Sbmtd_Chrg = $788.07 on the National facility row for 99284, alongside 4,531,103 services from 117,351 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 114.81,
      "evidence": "Avg_Mdcr_Alowd_Amt = $114.81 on the National facility row for 99284, alongside 4,531,103 services from 117,351 providers"
     }
    ],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 99284 (APC 5024)",
    "loinc": null,
    "check": "two published figures added, both re-read",
    "evidence": "hospital APC 5024 $426.30 + physician facility payment $118.24 = $544.54",
    "source_url": "https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient-pps/quarterly-addenda-updates/january-2026-addendum-b",
    "source_key": "oppsb+rvu",
    "extras": []
   }
  },
  {
   "id": "cms-ed-99284-facility-only",
   "label": "Emergency room — the HOSPITAL's half only",
   "plain_language_synonyms": [
    "hospital bill from the ER",
    "ER facility fee"
   ],
   "value_usd": 426.3,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": false,
   "mutually_exclusive_with": [
    "cms-ed-99284-complete"
   ],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national unadjusted",
   "population": "Medicare hospital outpatient beneficiaries at hospitals paid under the outpatient system",
   "coverage_statement": "Half of an ER bill, shown separately so the two halves are visible. Do not add this to the complete-visit figure above — that figure already contains it. Minimum Medicare copay $85.26. National unadjusted; each hospital's payment is adjusted by its local wage index. Does not apply to critical access hospitals, to freestanding emergency rooms outside the Medicare outpatient system, or to any non-Medicare patient. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it.",
   "source_title": "CMS, January 2026 Hospital Outpatient Prospective Payment System Addendum B",
   "source_url": "https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient-pps/quarterly-addenda-updates/january-2026-addendum-b",
   "confidence": "VERIFIED",
   "code": "CPT 99284 (APC 5024)",
   "alternates": null,
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-ed-99284-facility-only",
    "status": "PASS",
    "value_usd": 426.3,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 99284 (APC 5024)",
    "loinc": null,
    "check": "OPPS Addendum B lookup",
    "evidence": "99284 pays $426.30 under APC 5024, minimum unadjusted copayment $85.26",
    "source_url": "https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient-pps/quarterly-addenda-updates/january-2026-addendum-b",
    "source_key": "oppsb",
    "extras": []
   }
  },
  {
   "id": "cms-ed-99284-physician-only",
   "label": "Emergency room — the DOCTOR's half only",
   "plain_language_synonyms": [
    "ER doctor bill",
    "emergency physician bill"
   ],
   "value_usd": 118.24,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": false,
   "mutually_exclusive_with": [
    "cms-ed-99284-complete"
   ],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The emergency physician's professional fee alone — about a fifth of what the visit actually costs, because the hospital bills separately. Do not add this to the complete-visit figure above; that figure already contains it. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.54 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 99284",
   "alternates": null,
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-ed-99284-physician-only",
    "status": "PASS",
    "value_usd": 118.24,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 99284",
    "loinc": null,
    "check": "PFS re-derivation, facility setting",
    "evidence": "3.54 total facility RVUs x $33.4009 = $118.24",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-lab-cbc",
   "label": "Complete blood count",
   "plain_language_synonyms": [
    "bloodwork",
    "had my blood drawn",
    "blood test",
    "CBC",
    "blood count",
    "routine blood work"
   ],
   "value_usd": 7.77,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The standard blood count ordered at almost every workup visit. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and is the single most misleading number in this dataset if it is copied into an out-of-pocket column. If you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one. If you are uninsured you are billed the charge shown beside this figure. There is one national rate with no geographic adjustment, because Congress set it from reported private-payer rates. The average CHARGE submitted for this test in 2024 was $37.12 — 4.8 times this rate.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 85025",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 37.12,
    "cy2024_average_allowed_usd": 7.59,
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Renamed from a bare 'beneficiary_cost_share' field precisely so it cannot be read as what you paid. It must never populate an out-of-pocket column.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=85025, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_total_services": 26189197.1,
    "cy2024_rendering_providers": 54652,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "_allowed_note": "ALLOWED basis, CY2024, read on the same file row as the charge above: Medicare allowed $7.59 on average across 26,189,197 services. Our own figure for this test is the CY2026 rate shown at the top of this card; this is a second federal file saying what the same test actually settled at, and it is never added to anything."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "57021-8",
   "loinc_long_common_name": "CBC W Auto Differential panel - Blood",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-cbc",
    "status": "PASS",
    "value_usd": 7.77,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 37.12,
      "evidence": "Avg_Sbmtd_Chrg = $37.12 on the National office row for 85025, alongside 26,189,197 services from 54,652 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 7.59,
      "evidence": "Avg_Mdcr_Alowd_Amt = $7.59 on the National office row for 85025, alongside 26,189,197 services from 54,652 providers"
     }
    ],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 85025",
    "loinc": "57021-8",
    "check": "CLFS lookup",
    "evidence": "CPT 85025 pays $7.77 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-cmp",
   "label": "Comprehensive metabolic panel",
   "plain_language_synonyms": [
    "metabolic panel",
    "CMP",
    "chemistry panel",
    "liver and kidney blood test",
    "blood chemistry"
   ],
   "value_usd": 10.56,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The broad chemistry panel checking kidney, liver, sugar and electrolytes. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and is the single most misleading number in this dataset if it is copied into an out-of-pocket column. If you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one. If you are uninsured you are billed the charge shown beside this figure. There is one national rate with no geographic adjustment, because Congress set it from reported private-payer rates. The average CHARGE submitted for this test in 2024 was $61.45 — 5.8 times this rate.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 80053",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 61.45,
    "cy2024_average_allowed_usd": 10.33,
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Renamed from a bare 'beneficiary_cost_share' field precisely so it cannot be read as what you paid. It must never populate an out-of-pocket column.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=80053, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_total_services": 27211637.2,
    "cy2024_rendering_providers": 45390,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "_allowed_note": "ALLOWED basis, CY2024, read on the same file row as the charge above: Medicare allowed $10.33 on average across 27,211,637 services. Our own figure for this test is the CY2026 rate shown at the top of this card; this is a second federal file saying what the same test actually settled at, and it is never added to anything."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "24323-8",
   "loinc_long_common_name": "Comprehensive metabolic 2000 panel - Serum or Plasma",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-cmp",
    "status": "PASS",
    "value_usd": 10.56,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 61.45,
      "evidence": "Avg_Sbmtd_Chrg = $61.45 on the National office row for 80053, alongside 27,211,637 services from 45,390 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 10.33,
      "evidence": "Avg_Mdcr_Alowd_Amt = $10.33 on the National office row for 80053, alongside 27,211,637 services from 45,390 providers"
     }
    ],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 80053",
    "loinc": "24323-8",
    "check": "CLFS lookup",
    "evidence": "CPT 80053 pays $10.56 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-bmp",
   "label": "Basic metabolic panel",
   "plain_language_synonyms": [
    "basic panel",
    "BMP",
    "electrolytes"
   ],
   "value_usd": 8.46,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The shorter chemistry panel, ordered instead of the comprehensive one. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and is the single most misleading number in this dataset if it is copied into an out-of-pocket column. If you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one. If you are uninsured you are billed the charge shown beside this figure. There is one national rate with no geographic adjustment, because Congress set it from reported private-payer rates. The average CHARGE submitted for this test in 2024 was $47.97 — 5.7 times this rate.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 80048",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 47.97,
    "cy2024_average_allowed_usd": 8.27,
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Renamed from a bare 'beneficiary_cost_share' field precisely so it cannot be read as what you paid. It must never populate an out-of-pocket column.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=80048, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_total_services": 5130544,
    "cy2024_rendering_providers": 31822,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "_allowed_note": "ALLOWED basis, CY2024, read on the same file row as the charge above: Medicare allowed $8.27 on average across 5,130,544 services. Our own figure for this test is the CY2026 rate shown at the top of this card; this is a second federal file saying what the same test actually settled at, and it is never added to anything."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "24321-2",
   "loinc_long_common_name": "Basic metabolic 2000 panel - Serum or Plasma",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-bmp",
    "status": "PASS",
    "value_usd": 8.46,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 47.97,
      "evidence": "Avg_Sbmtd_Chrg = $47.97 on the National office row for 80048, alongside 5,130,544 services from 31,822 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 8.27,
      "evidence": "Avg_Mdcr_Alowd_Amt = $8.27 on the National office row for 80048, alongside 5,130,544 services from 31,822 providers"
     }
    ],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 80048",
    "loinc": "24321-2",
    "check": "CLFS lookup",
    "evidence": "CPT 80048 pays $8.46 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-tsh",
   "label": "Thyroid test (TSH)",
   "plain_language_synonyms": [
    "thyroid test",
    "TSH",
    "checked my thyroid",
    "thyroid blood test"
   ],
   "value_usd": 16.8,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "Ordered in nearly every fatigue workup, because an underactive thyroid mimics the same symptoms. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and is the single most misleading number in this dataset if it is copied into an out-of-pocket column. If you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one. If you are uninsured you are billed the charge shown beside this figure. There is one national rate with no geographic adjustment, because Congress set it from reported private-payer rates. The average CHARGE submitted for this test in 2024 was $95.90 — 5.7 times this rate.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 84443",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 95.9,
    "cy2024_average_allowed_usd": 16.44,
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Renamed from a bare 'beneficiary_cost_share' field precisely so it cannot be read as what you paid. It must never populate an out-of-pocket column.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=84443, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_total_services": 13896671,
    "cy2024_rendering_providers": 32960,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "_allowed_note": "ALLOWED basis, CY2024, read on the same file row as the charge above: Medicare allowed $16.44 on average across 13,896,671 services. Our own figure for this test is the CY2026 rate shown at the top of this card; this is a second federal file saying what the same test actually settled at, and it is never added to anything."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "3016-3",
   "loinc_long_common_name": "Thyrotropin [Units/volume] in Serum or Plasma",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-tsh",
    "status": "PASS",
    "value_usd": 16.8,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 95.9,
      "evidence": "Avg_Sbmtd_Chrg = $95.90 on the National office row for 84443, alongside 13,896,671 services from 32,960 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 16.44,
      "evidence": "Avg_Mdcr_Alowd_Amt = $16.44 on the National office row for 84443, alongside 13,896,671 services from 32,960 providers"
     }
    ],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 84443",
    "loinc": "3016-3",
    "check": "CLFS lookup",
    "evidence": "CPT 84443 pays $16.80 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-ana",
   "label": "Autoimmune screen (ANA)",
   "plain_language_synonyms": [
    "ANA",
    "autoimmune test",
    "lupus test",
    "antinuclear antibody",
    "tested me for autoimmune"
   ],
   "value_usd": 12.09,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The autoimmune screen ordered when symptoms suggest a rheumatologic disease. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and is the single most misleading number in this dataset if it is copied into an out-of-pocket column. If you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one. If you are uninsured you are billed the charge shown beside this figure. There is one national rate with no geographic adjustment, because Congress set it from reported private-payer rates. The average CHARGE submitted for this test in 2024 was $81.33 — 6.7 times this rate. A positive result routinely triggers a rheumatology referral and a second round of testing, so this inexpensive test is often the branch point into expensive care.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 86038",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 81.33,
    "cy2024_average_allowed_usd": 11.83,
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Renamed from a bare 'beneficiary_cost_share' field precisely so it cannot be read as what you paid. It must never populate an out-of-pocket column.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=86038, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_total_services": 684386,
    "cy2024_rendering_providers": 4162,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "_allowed_note": "ALLOWED basis, CY2024, read on the same file row as the charge above: Medicare allowed $11.83 on average across 684,386 services. Our own figure for this test is the CY2026 rate shown at the top of this card; this is a second federal file saying what the same test actually settled at, and it is never added to anything."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "5048-4",
   "loinc_long_common_name": "Nuclear Ab [Titer] in Serum by Immunofluorescence",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-ana",
    "status": "PASS",
    "value_usd": 12.09,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 81.33,
      "evidence": "Avg_Sbmtd_Chrg = $81.33 on the National office row for 86038, alongside 684,386 services from 4,162 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 11.83,
      "evidence": "Avg_Mdcr_Alowd_Amt = $11.83 on the National office row for 86038, alongside 684,386 services from 4,162 providers"
     }
    ],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 86038",
    "loinc": "5048-4",
    "check": "CLFS lookup",
    "evidence": "CPT 86038 pays $12.09 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-esr",
   "label": "Inflammation test (ESR)",
   "plain_language_synonyms": [
    "sed rate",
    "ESR",
    "inflammation test",
    "sedimentation rate"
   ],
   "value_usd": 2.7,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The cheapest test in the whole workup. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and is the single most misleading number in this dataset if it is copied into an out-of-pocket column. If you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one. If you are uninsured you are billed the charge shown beside this figure. There is one national rate with no geographic adjustment, because Congress set it from reported private-payer rates. The average CHARGE submitted for this test in 2024 was $29.54 — 10.9 times this rate. The gap between this rate and the charge is the widest of any common lab here, which is exactly the kind of gap an uninsured person absorbs.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 85652",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 29.54,
    "cy2024_average_allowed_usd": 2.64,
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Renamed from a bare 'beneficiary_cost_share' field precisely so it cannot be read as what you paid. It must never populate an out-of-pocket column.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=85652, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_total_services": 2160438,
    "cy2024_rendering_providers": 13607,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "_allowed_note": "ALLOWED basis, CY2024, read on the same file row as the charge above: Medicare allowed $2.64 on average across 2,160,438 services. Our own figure for this test is the CY2026 rate shown at the top of this card; this is a second federal file saying what the same test actually settled at, and it is never added to anything."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "30341-2",
   "loinc_long_common_name": "Erythrocyte [Sedimentation Rate] in Blood",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-esr",
    "status": "PASS",
    "value_usd": 2.7,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 29.54,
      "evidence": "Avg_Sbmtd_Chrg = $29.54 on the National office row for 85652, alongside 2,160,438 services from 13,607 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 2.64,
      "evidence": "Avg_Mdcr_Alowd_Amt = $2.64 on the National office row for 85652, alongside 2,160,438 services from 13,607 providers"
     }
    ],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 85652",
    "loinc": "30341-2",
    "check": "CLFS lookup",
    "evidence": "CPT 85652 pays $2.70 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-crp",
   "label": "Inflammation test (CRP)",
   "plain_language_synonyms": [
    "CRP",
    "C-reactive protein",
    "inflammation marker"
   ],
   "value_usd": 5.18,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The standard inflammatory marker. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and is the single most misleading number in this dataset if it is copied into an out-of-pocket column. If you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one. If you are uninsured you are billed the charge shown beside this figure. There is one national rate with no geographic adjustment, because Congress set it from reported private-payer rates. The average CHARGE submitted for this test in 2024 was $55.53 — 10.7 times this rate. A high-sensitivity version exists as a separate test at $12.95. Labs differ in which they run, and using the wrong one misprices this line by two and a half times.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 86140",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 55.53,
    "cy2024_average_allowed_usd": 5.07,
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Renamed from a bare 'beneficiary_cost_share' field precisely so it cannot be read as what you paid. It must never populate an out-of-pocket column.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=86140, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_total_services": 2378356,
    "cy2024_rendering_providers": 16048,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "_allowed_note": "ALLOWED basis, CY2024, read on the same file row as the charge above: Medicare allowed $5.07 on average across 2,378,356 services. Our own figure for this test is the CY2026 rate shown at the top of this card; this is a second federal file saying what the same test actually settled at, and it is never added to anything."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "1988-5",
   "loinc_long_common_name": "C reactive protein [Mass/volume] in Serum or Plasma",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-crp",
    "status": "PASS",
    "value_usd": 5.18,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 55.53,
      "evidence": "Avg_Sbmtd_Chrg = $55.53 on the National office row for 86140, alongside 2,378,356 services from 16,048 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 5.07,
      "evidence": "Avg_Mdcr_Alowd_Amt = $5.07 on the National office row for 86140, alongside 2,378,356 services from 16,048 providers"
     }
    ],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 86140",
    "loinc": "1988-5",
    "check": "CLFS lookup",
    "evidence": "CPT 86140 pays $5.18 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-hscrp",
   "label": "High-sensitivity CRP",
   "plain_language_synonyms": [
    "hs-CRP",
    "high sensitivity CRP"
   ],
   "value_usd": 12.95,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A more sensitive version of the C-reactive protein test — a different test, not the same one. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and is the single most misleading number in this dataset if it is copied into an out-of-pocket column. If you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one. If you are uninsured you are billed the charge shown beside this figure. There is one national rate with no geographic adjustment, because Congress set it from reported private-payer rates. The average CHARGE submitted for this test in 2024 was $70.03 — 5.4 times this rate.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 86141",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 70.03,
    "cy2024_average_allowed_usd": 12.67,
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Renamed from a bare 'beneficiary_cost_share' field precisely so it cannot be read as what you paid. It must never populate an out-of-pocket column.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=86141, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_total_services": 499083,
    "cy2024_rendering_providers": 2959,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "_allowed_note": "ALLOWED basis, CY2024, read on the same file row as the charge above: Medicare allowed $12.67 on average across 499,083 services. Our own figure for this test is the CY2026 rate shown at the top of this card; this is a second federal file saying what the same test actually settled at, and it is never added to anything."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "30522-7",
   "loinc_long_common_name": "C reactive protein [Mass/volume] in Serum or Plasma by High sensitivity method",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-hscrp",
    "status": "PASS",
    "value_usd": 12.95,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 70.03,
      "evidence": "Avg_Sbmtd_Chrg = $70.03 on the National office row for 86141, alongside 499,083 services from 2,959 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 12.67,
      "evidence": "Avg_Mdcr_Alowd_Amt = $12.67 on the National office row for 86141, alongside 499,083 services from 2,959 providers"
     }
    ],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 86141",
    "loinc": "30522-7",
    "check": "CLFS lookup",
    "evidence": "CPT 86141 pays $12.95 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-ddimer",
   "label": "D-dimer (clot test)",
   "plain_language_synonyms": [
    "D-dimer",
    "clot test",
    "tested for a blood clot",
    "checked for a clot",
    "PE test"
   ],
   "value_usd": 10.18,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "Ordered to rule out a lung clot when someone reports breathlessness. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and is the single most misleading number in this dataset if it is copied into an out-of-pocket column. If you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one. If you are uninsured you are billed the charge shown beside this figure. There is one national rate with no geographic adjustment, because Congress set it from reported private-payer rates. The average CHARGE submitted for this test in 2024 was $129.04 — 12.7 times this rate. This inexpensive test is a major branch point: a positive result routinely triggers a chest CT costing roughly sixteen times as much.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 85379",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 129.04,
    "cy2024_average_allowed_usd": 9.96,
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Renamed from a bare 'beneficiary_cost_share' field precisely so it cannot be read as what you paid. It must never populate an out-of-pocket column.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=85379, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_total_services": 139977,
    "cy2024_rendering_providers": 5418,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "_allowed_note": "ALLOWED basis, CY2024, read on the same file row as the charge above: Medicare allowed $9.96 on average across 139,977 services. Our own figure for this test is the CY2026 rate shown at the top of this card; this is a second federal file saying what the same test actually settled at, and it is never added to anything."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "48065-7",
   "loinc_long_common_name": "Fibrin D-dimer FEU [Mass/volume] in Platelet poor plasma",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-ddimer",
    "status": "PASS",
    "value_usd": 10.18,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 129.04,
      "evidence": "Avg_Sbmtd_Chrg = $129.04 on the National office row for 85379, alongside 139,977 services from 5,418 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 9.96,
      "evidence": "Avg_Mdcr_Alowd_Amt = $9.96 on the National office row for 85379, alongside 139,977 services from 5,418 providers"
     }
    ],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 85379",
    "loinc": "48065-7",
    "check": "CLFS lookup",
    "evidence": "CPT 85379 pays $10.18 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-ferritin",
   "label": "Ferritin (iron stores)",
   "plain_language_synonyms": [
    "ferritin",
    "iron test",
    "iron levels",
    "checked my iron"
   ],
   "value_usd": 13.63,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "Iron-storage protein, ordered in fatigue workups. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and is the single most misleading number in this dataset if it is copied into an out-of-pocket column. If you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one. If you are uninsured you are billed the charge shown beside this figure. There is one national rate with no geographic adjustment, because Congress set it from reported private-payer rates. The average CHARGE submitted for this test in 2024 was $78.75 — 5.8 times this rate.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 82728",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 78.75,
    "cy2024_average_allowed_usd": 13.33,
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Renamed from a bare 'beneficiary_cost_share' field precisely so it cannot be read as what you paid. It must never populate an out-of-pocket column.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=82728, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_total_services": 3450027,
    "cy2024_rendering_providers": 21739,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "_allowed_note": "ALLOWED basis, CY2024, read on the same file row as the charge above: Medicare allowed $13.33 on average across 3,450,027 services. Our own figure for this test is the CY2026 rate shown at the top of this card; this is a second federal file saying what the same test actually settled at, and it is never added to anything."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "2276-4",
   "loinc_long_common_name": "Ferritin [Mass/volume] in Serum or Plasma",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-ferritin",
    "status": "PASS",
    "value_usd": 13.63,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 78.75,
      "evidence": "Avg_Sbmtd_Chrg = $78.75 on the National office row for 82728, alongside 3,450,027 services from 21,739 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 13.33,
      "evidence": "Avg_Mdcr_Alowd_Amt = $13.33 on the National office row for 82728, alongside 3,450,027 services from 21,739 providers"
     }
    ],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 82728",
    "loinc": "2276-4",
    "check": "CLFS lookup",
    "evidence": "CPT 82728 pays $13.63 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-lyme-screen",
   "label": "Lyme disease screening test",
   "plain_language_synonyms": [
    "Lyme test",
    "tested me for Lyme",
    "Lyme screen",
    "tick disease test"
   ],
   "value_usd": 17.03,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "Ordered because late-stage Lyme disease overlaps with the long COVID symptom picture. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and is the single most misleading number in this dataset if it is copied into an out-of-pocket column. If you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one. If you are uninsured you are billed the charge shown beside this figure. There is one national rate with no geographic adjustment, because Congress set it from reported private-payer rates. The average CHARGE submitted for this test in 2024 was $142.89 — 8.4 times this rate. Standard practice is two-tier: a reactive screen adds a confirmatory test at $15.49, making a full positive workup $32.52. In 2024 about 78 percent as many confirmations as screens were billed, so a ledger should not assume everyone screened gets one.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 86618",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 142.89,
    "cy2024_average_allowed_usd": 16.67,
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Renamed from a bare 'beneficiary_cost_share' field precisely so it cannot be read as what you paid. It must never populate an out-of-pocket column.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=86618, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_total_services": 166407,
    "cy2024_rendering_providers": 2982,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "_allowed_note": "ALLOWED basis, CY2024, read on the same file row as the charge above: Medicare allowed $16.67 on average across 166,407 services. Our own figure for this test is the CY2026 rate shown at the top of this card; this is a second federal file saying what the same test actually settled at, and it is never added to anything."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-lab-lyme-screen",
    "status": "PASS",
    "value_usd": 17.03,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 142.89,
      "evidence": "Avg_Sbmtd_Chrg = $142.89 on the National office row for 86618, alongside 166,407 services from 2,982 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 16.67,
      "evidence": "Avg_Mdcr_Alowd_Amt = $16.67 on the National office row for 86618, alongside 166,407 services from 2,982 providers"
     }
    ],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 86618",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 86618 pays $17.03 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-lyme-confirm",
   "label": "Lyme disease confirmatory test",
   "plain_language_synonyms": [
    "Lyme confirmation",
    "Western blot",
    "second Lyme test"
   ],
   "value_usd": 15.49,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The second tier of Lyme testing, run only when the screen comes back reactive. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and is the single most misleading number in this dataset if it is copied into an out-of-pocket column. If you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one. If you are uninsured you are billed the charge shown beside this figure. There is one national rate with no geographic adjustment, because Congress set it from reported private-payer rates. The average CHARGE submitted for this test in 2024 was $112.73 — 7.3 times this rate.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 86617",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 112.73,
    "cy2024_average_allowed_usd": 15.17,
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Renamed from a bare 'beneficiary_cost_share' field precisely so it cannot be read as what you paid. It must never populate an out-of-pocket column.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=86617, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_total_services": 129177,
    "cy2024_rendering_providers": 503,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "_allowed_note": "ALLOWED basis, CY2024, read on the same file row as the charge above: Medicare allowed $15.17 on average across 129,177 services. Our own figure for this test is the CY2026 rate shown at the top of this card; this is a second federal file saying what the same test actually settled at, and it is never added to anything."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-lab-lyme-confirm",
    "status": "PASS",
    "value_usd": 15.49,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 112.73,
      "evidence": "Avg_Sbmtd_Chrg = $112.73 on the National office row for 86617, alongside 129,177 services from 503 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 15.17,
      "evidence": "Avg_Mdcr_Alowd_Amt = $15.17 on the National office row for 86617, alongside 129,177 services from 503 providers"
     }
    ],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 86617",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 86617 pays $15.49 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-img-cxr",
   "label": "Chest X-ray, two views",
   "plain_language_synonyms": [
    "chest x-ray",
    "x-ray",
    "chest film",
    "they x-rayed my chest",
    "lung x-ray"
   ],
   "value_usd": 33.07,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The image and the radiologist's reading together, done at a freestanding imaging office. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.99 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $89.42 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one. In a HOSPITAL the same X-ray costs about three times as much, because the hospital bills its own $88.91 fee and the radiologist bills the reading separately.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 71046",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 89.42,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 23.13,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "hospital_outpatient_facility_fee_usd": 88.91,
    "hospital_outpatient_facility_fee_source": "CMS, January 2026 Hospital Outpatient Prospective Payment System Addendum B",
    "_opps_note": "If this happened inside a hospital-owned clinic or hospital department rather than a freestanding office, the hospital bills THIS fee in addition to the clinician's fee. Long COVID clinics are disproportionately hospital-based, so this is often the applicable path, not the exception.",
    "hospital_outpatient_minimum_beneficiary_copay_usd": 17.79,
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=71046, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 3250829,
    "cy2024_rendering_providers": 86953,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_physician_payment_usd": 10.02,
    "facility_setting_total_rvu": 0.3,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 0.30 facility total RVUs on the modifier 26 line x $33.4009 = $10.02 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-img-cxr",
    "status": "PASS",
    "value_usd": 33.07,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 89.42,
      "evidence": "Avg_Sbmtd_Chrg = $89.42 on the National office row for 71046, alongside 3,250,829 services from 86,953 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 23.13,
      "evidence": "Avg_Mdcr_Alowd_Amt = $23.13 on the National office row for 71046, alongside 3,250,829 services from 86,953 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 10.02,
      "evidence": "0.30 facility total RVUs on the modifier 26 line for 71046 x $33.4009 = $10.02"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 71046",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.99 total non-facility RVUs x $33.4009 = $33.07",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-ct-chest-nc",
   "label": "CT scan of the chest, without contrast",
   "plain_language_synonyms": [
    "CT scan",
    "chest CT",
    "CAT scan",
    "cat scan of my chest",
    "scanned my lungs"
   ],
   "value_usd": 132.6,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The scan and the reading together, at a freestanding imaging center. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.97 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $671.96 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 71250",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 671.96,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 97.8,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "hospital_outpatient_facility_fee_usd": 106.81,
    "hospital_outpatient_facility_fee_source": "CMS, January 2026 Hospital Outpatient Prospective Payment System Addendum B",
    "_opps_note": "If this happened inside a hospital-owned clinic or hospital department rather than a freestanding office, the hospital bills THIS fee in addition to the clinician's fee. Long COVID clinics are disproportionately hospital-based, so this is often the applicable path, not the exception.",
    "hospital_outpatient_minimum_beneficiary_copay_usd": 21.37,
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=71250, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 882795,
    "cy2024_rendering_providers": 21207,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_physician_payment_usd": 49.43,
    "facility_setting_total_rvu": 1.48,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.48 facility total RVUs on the modifier 26 line x $33.4009 = $49.43 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-img-ct-chest-nc",
    "status": "PASS",
    "value_usd": 132.6,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 671.96,
      "evidence": "Avg_Sbmtd_Chrg = $671.96 on the National office row for 71250, alongside 882,795 services from 21,207 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 97.8,
      "evidence": "Avg_Mdcr_Alowd_Amt = $97.80 on the National office row for 71250, alongside 882,795 services from 21,207 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 49.43,
      "evidence": "1.48 facility total RVUs on the modifier 26 line for 71250 x $33.4009 = $49.43"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 71250",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.97 total non-facility RVUs x $33.4009 = $132.60",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-ct-chest-c",
   "label": "CT scan of the chest, with contrast",
   "plain_language_synonyms": [
    "CT with contrast",
    "CT angiogram",
    "chest CT with dye",
    "scanned for a clot"
   ],
   "value_usd": 166.67,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The scan typically ordered on a positive clot test, to rule out a clot in the lung. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 4.99 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $704.47 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 71260",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 704.47,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 84.2,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "hospital_outpatient_facility_fee_usd": 179.2,
    "hospital_outpatient_facility_fee_source": "CMS, January 2026 Hospital Outpatient Prospective Payment System Addendum B",
    "_opps_note": "If this happened inside a hospital-owned clinic or hospital department rather than a freestanding office, the hospital bills THIS fee in addition to the clinician's fee. Long COVID clinics are disproportionately hospital-based, so this is often the applicable path, not the exception.",
    "hospital_outpatient_minimum_beneficiary_copay_usd": 35.84,
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=71260, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 588994,
    "cy2024_rendering_providers": 18880,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_physician_payment_usd": 53.78,
    "facility_setting_total_rvu": 1.61,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.61 facility total RVUs on the modifier 26 line x $33.4009 = $53.78 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-img-ct-chest-c",
    "status": "PASS",
    "value_usd": 166.67,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 704.47,
      "evidence": "Avg_Sbmtd_Chrg = $704.47 on the National office row for 71260, alongside 588,994 services from 18,880 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 84.2,
      "evidence": "Avg_Mdcr_Alowd_Amt = $84.20 on the National office row for 71260, alongside 588,994 services from 18,880 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 53.78,
      "evidence": "1.61 facility total RVUs on the modifier 26 line for 71260 x $33.4009 = $53.78"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 71260",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "4.99 total non-facility RVUs x $33.4009 = $166.67",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-echo",
   "label": "Echocardiogram (ultrasound of the heart)",
   "plain_language_synonyms": [
    "echo",
    "echocardiogram",
    "heart ultrasound",
    "ultrasound of my heart",
    "they scanned my heart",
    "echo of my heart"
   ],
   "value_usd": 196.73,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The standard heart study when someone reports palpitations or cannot tolerate exertion. Includes the scan and the cardiologist's reading, done in a cardiology office. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 5.89 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $690.55 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one. This is the largest address-driven price difference in the entire workup. In a hospital, the hospital's own fee is $558.25 and the cardiologist bills the reading on top, so the same echocardiogram costs about $625 instead of about $197. A Medicare patient's minimum copay on the hospital half alone is $111.65 — the highest patient copay of any single test here.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 93306",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 690.55,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 173.1,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "hospital_outpatient_facility_fee_usd": 558.25,
    "hospital_outpatient_facility_fee_source": "CMS, January 2026 Hospital Outpatient Prospective Payment System Addendum B",
    "_opps_note": "If this happened inside a hospital-owned clinic or hospital department rather than a freestanding office, the hospital bills THIS fee in addition to the clinician's fee. Long COVID clinics are disproportionately hospital-based, so this is often the applicable path, not the exception.",
    "hospital_outpatient_minimum_beneficiary_copay_usd": 111.65,
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=93306, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 2948622,
    "cy2024_rendering_providers": 28683,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_physician_payment_usd": 67.47,
    "facility_setting_total_rvu": 2.02,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 2.02 facility total RVUs on the modifier 26 line x $33.4009 = $67.47 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-img-echo",
    "status": "PASS",
    "value_usd": 196.73,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 690.55,
      "evidence": "Avg_Sbmtd_Chrg = $690.55 on the National office row for 93306, alongside 2,948,622 services from 28,683 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 173.1,
      "evidence": "Avg_Mdcr_Alowd_Amt = $173.10 on the National office row for 93306, alongside 2,948,622 services from 28,683 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 67.47,
      "evidence": "2.02 facility total RVUs on the modifier 26 line for 93306 x $33.4009 = $67.47"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 93306",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "5.89 total non-facility RVUs x $33.4009 = $196.73",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-mri-brain-nc",
   "label": "MRI of the brain, without contrast",
   "plain_language_synonyms": [
    "brain MRI",
    "MRI of my head",
    "head scan",
    "MRI"
   ],
   "value_usd": 195.4,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The scan and the reading together, at a freestanding imaging center. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 5.85 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $1,290.96 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 70551",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 1290.96,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 155.06,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "hospital_outpatient_facility_fee_usd": 243.77,
    "hospital_outpatient_facility_fee_source": "CMS, January 2026 Hospital Outpatient Prospective Payment System Addendum B",
    "_opps_note": "If this happened inside a hospital-owned clinic or hospital department rather than a freestanding office, the hospital bills THIS fee in addition to the clinician's fee. Long COVID clinics are disproportionately hospital-based, so this is often the applicable path, not the exception.",
    "hospital_outpatient_minimum_beneficiary_copay_usd": 48.76,
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=70551, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 349977,
    "cy2024_rendering_providers": 11590,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_physician_payment_usd": 67.8,
    "facility_setting_total_rvu": 2.03,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 2.03 facility total RVUs on the modifier 26 line x $33.4009 = $67.80 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-img-mri-brain-nc",
    "status": "PASS",
    "value_usd": 195.4,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 1290.96,
      "evidence": "Avg_Sbmtd_Chrg = $1290.96 on the National office row for 70551, alongside 349,977 services from 11,590 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 155.06,
      "evidence": "Avg_Mdcr_Alowd_Amt = $155.06 on the National office row for 70551, alongside 349,977 services from 11,590 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 67.8,
      "evidence": "2.03 facility total RVUs on the modifier 26 line for 70551 x $33.4009 = $67.80"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 70551",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "5.85 total non-facility RVUs x $33.4009 = $195.40",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-mri-brain-both",
   "label": "MRI of the brain, with and without contrast",
   "plain_language_synonyms": [
    "brain MRI with contrast",
    "MRI with dye",
    "full brain MRI",
    "MRI for brain fog"
   ],
   "value_usd": 316.97,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The most expensive single study in a standard long COVID workup — usually ordered for the cognitive symptoms people call brain fog, and it almost always comes back normal, which is exactly what makes it part of the odyssey rather than the end of it. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 9.49 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $1,918.76 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one. This line carries the widest gap in the whole dataset between what Medicare pays and what a provider bills: $316.97 against an average submitted charge of $1,918.76. That roughly $1,600 spread is the clearest single illustration of why an uninsured person's odyssey costs a multiple of an insured person's. In a hospital, the hospital's fee is $356.43 and the radiologist bills the reading separately.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 70553",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 1918.76,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 229.98,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "hospital_outpatient_facility_fee_usd": 356.43,
    "hospital_outpatient_facility_fee_source": "CMS, January 2026 Hospital Outpatient Prospective Payment System Addendum B",
    "_opps_note": "If this happened inside a hospital-owned clinic or hospital department rather than a freestanding office, the hospital bills THIS fee in addition to the clinician's fee. Long COVID clinics are disproportionately hospital-based, so this is often the applicable path, not the exception.",
    "hospital_outpatient_minimum_beneficiary_copay_usd": 71.29,
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=70553, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 416344,
    "cy2024_rendering_providers": 11400,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_physician_payment_usd": 105.21,
    "facility_setting_total_rvu": 3.15,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 3.15 facility total RVUs on the modifier 26 line x $33.4009 = $105.21 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-img-mri-brain-both",
    "status": "PASS",
    "value_usd": 316.97,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 1918.76,
      "evidence": "Avg_Sbmtd_Chrg = $1918.76 on the National office row for 70553, alongside 416,344 services from 11,400 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 229.98,
      "evidence": "Avg_Mdcr_Alowd_Amt = $229.98 on the National office row for 70553, alongside 416,344 services from 11,400 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 105.21,
      "evidence": "3.15 facility total RVUs on the modifier 26 line for 70553 x $33.4009 = $105.21"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 70553",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "9.49 total non-facility RVUs x $33.4009 = $316.97",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-spirometry",
   "label": "Breathing test (spirometry)",
   "plain_language_synonyms": [
    "breathing test",
    "spirometry",
    "blew into a tube",
    "lung function test",
    "PFT",
    "pulmonary function test",
    "they tested my breathing"
   ],
   "value_usd": 29.73,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The basic breathing test, rarely done alone in a breathlessness workup. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.89 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $96.77 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one. In a hospital pulmonary lab the hospital's own fee for this is $220.60 — more than seven times the office rate, one of the sharpest address-driven differences here.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 94010",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 96.77,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 25.49,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "hospital_outpatient_facility_fee_usd": 220.6,
    "hospital_outpatient_facility_fee_source": "CMS, January 2026 Hospital Outpatient Prospective Payment System Addendum B",
    "_opps_note": "If this happened inside a hospital-owned clinic or hospital department rather than a freestanding office, the hospital bills THIS fee in addition to the clinician's fee. Long COVID clinics are disproportionately hospital-based, so this is often the applicable path, not the exception.",
    "hospital_outpatient_minimum_beneficiary_copay_usd": 44.12,
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=94010, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 615658,
    "cy2024_rendering_providers": 18915,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_physician_payment_usd": 8.35,
    "facility_setting_total_rvu": 0.25,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 0.25 facility total RVUs on the modifier 26 line x $33.4009 = $8.35 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-test-spirometry",
    "status": "PASS",
    "value_usd": 29.73,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 96.77,
      "evidence": "Avg_Sbmtd_Chrg = $96.77 on the National office row for 94010, alongside 615,658 services from 18,915 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 25.49,
      "evidence": "Avg_Mdcr_Alowd_Amt = $25.49 on the National office row for 94010, alongside 615,658 services from 18,915 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 8.35,
      "evidence": "0.25 facility total RVUs on the modifier 26 line for 94010 x $33.4009 = $8.35"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 94010",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.89 total non-facility RVUs x $33.4009 = $29.73",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-dlco",
   "label": "Gas transfer test (diffusing capacity)",
   "plain_language_synonyms": [
    "DLCO",
    "diffusion test",
    "gas transfer test",
    "lung diffusion"
   ],
   "value_usd": 63.46,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The most diagnostically important lung test in long COVID, because reduced gas transfer is one of the few objective abnormalities that is actually found. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.9 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $150.43 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one. This is an add-on billed alongside spirometry, not a standalone test. Note one quirk: a hospital receives no separate payment for it at all — Medicare packages its cost into the primary test.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 94729, add-on",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 150.43,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 51.03,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=94729, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 591662,
    "cy2024_rendering_providers": 8681,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_physician_payment_usd": 9.35,
    "facility_setting_total_rvu": 0.28,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 0.28 facility total RVUs on the modifier 26 line x $33.4009 = $9.35 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-test-dlco",
    "status": "PASS",
    "value_usd": 63.46,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 150.43,
      "evidence": "Avg_Sbmtd_Chrg = $150.43 on the National office row for 94729, alongside 591,662 services from 8,681 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 51.03,
      "evidence": "Avg_Mdcr_Alowd_Amt = $51.03 on the National office row for 94729, alongside 591,662 services from 8,681 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 9.35,
      "evidence": "0.28 facility total RVUs on the modifier 26 line for 94729 x $33.4009 = $9.35"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 94729, add-on",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.90 total non-facility RVUs x $33.4009 = $63.46",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-lung-volumes",
   "label": "Lung volume test",
   "plain_language_synonyms": [
    "lung volumes",
    "plethysmography",
    "body box",
    "lung volume test"
   ],
   "value_usd": 49.77,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The third part of a complete breathing-test set. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.49 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $118.27 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 94727",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 118.27,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 42.8,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "hospital_outpatient_facility_fee_usd": 220.6,
    "hospital_outpatient_facility_fee_source": "CMS, January 2026 Hospital Outpatient Prospective Payment System Addendum B",
    "_opps_note": "If this happened inside a hospital-owned clinic or hospital department rather than a freestanding office, the hospital bills THIS fee in addition to the clinician's fee. Long COVID clinics are disproportionately hospital-based, so this is often the applicable path, not the exception.",
    "hospital_outpatient_minimum_beneficiary_copay_usd": 44.12,
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=94727, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 185282,
    "cy2024_rendering_providers": 3887,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_physician_payment_usd": 12.02,
    "facility_setting_total_rvu": 0.36,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 0.36 facility total RVUs on the modifier 26 line x $33.4009 = $12.02 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-test-lung-volumes",
    "status": "PASS",
    "value_usd": 49.77,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 118.27,
      "evidence": "Avg_Sbmtd_Chrg = $118.27 on the National office row for 94727, alongside 185,282 services from 3,887 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 42.8,
      "evidence": "Avg_Mdcr_Alowd_Amt = $42.80 on the National office row for 94727, alongside 185,282 services from 3,887 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 12.02,
      "evidence": "0.36 facility total RVUs on the modifier 26 line for 94727 x $33.4009 = $12.02"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 94727",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.49 total non-facility RVUs x $33.4009 = $49.77",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-tilt-table",
   "label": "Tilt-table test",
   "plain_language_synonyms": [
    "tilt table",
    "tilt table test",
    "POTS test",
    "tested me for POTS",
    "test for dizziness standing up",
    "orthostatic test",
    "tilt test",
    "table tilt test"
   ],
   "value_usd": 168.34,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The definitive test for POTS and orthostatic intolerance — among the most commonly and objectively diagnosable long COVID problems. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 5.04 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $633.56 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one. A caution about how thin the underlying experience is: only 8,713 of these were billed to Medicare nationwide in 2024. The rate is well established, but Medicare's population is not where POTS is usually diagnosed, so almost none of that experience is with patients like the ones this tool serves. In a hospital the facility fee is $381.24 on top of the physician's fee.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 93660",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 633.56,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 145.23,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "hospital_outpatient_facility_fee_usd": 381.24,
    "hospital_outpatient_facility_fee_source": "CMS, January 2026 Hospital Outpatient Prospective Payment System Addendum B",
    "_opps_note": "If this happened inside a hospital-owned clinic or hospital department rather than a freestanding office, the hospital bills THIS fee in addition to the clinician's fee. Long COVID clinics are disproportionately hospital-based, so this is often the applicable path, not the exception.",
    "hospital_outpatient_minimum_beneficiary_copay_usd": 76.25,
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=93660, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 1957,
    "cy2024_rendering_providers": 283,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_physician_payment_usd": 89.85,
    "facility_setting_total_rvu": 2.69,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 2.69 facility total RVUs on the modifier 26 line x $33.4009 = $89.85 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-test-tilt-table",
    "status": "PASS",
    "value_usd": 168.34,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 633.56,
      "evidence": "Avg_Sbmtd_Chrg = $633.56 on the National office row for 93660, alongside 1,957 services from 283 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 145.23,
      "evidence": "Avg_Mdcr_Alowd_Amt = $145.23 on the National office row for 93660, alongside 1,957 services from 283 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 89.85,
      "evidence": "2.69 facility total RVUs on the modifier 26 line for 93660 x $33.4009 = $89.85"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 93660",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "5.04 total non-facility RVUs x $33.4009 = $168.34",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-cpet",
   "label": "Exercise stress test with breathing measurement (CPET)",
   "plain_language_synonyms": [
    "CPET",
    "exercise test",
    "cardiopulmonary exercise test",
    "bike test",
    "treadmill test with a mask",
    "exercise testing",
    "treadmill test",
    "stress test with breathing"
   ],
   "value_usd": 165.67,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The test that most reliably demonstrates post-exertional malaise — the crash after activity — as something objective rather than reported. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 4.96 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $401.97 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one. Two honest limits. Only 16,483 of these were billed to Medicare nationwide in 2024, so this is a rare test in that population. And many long COVID patients are told a TWO-DAY protocol is needed to show the crash; that doubles this figure, has no separate code, and is frequently not covered by any payer — a real cost that no fee schedule can see.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 94621",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 401.97,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 134.11,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "hospital_outpatient_facility_fee_usd": 381.24,
    "hospital_outpatient_facility_fee_source": "CMS, January 2026 Hospital Outpatient Prospective Payment System Addendum B",
    "_opps_note": "If this happened inside a hospital-owned clinic or hospital department rather than a freestanding office, the hospital bills THIS fee in addition to the clinician's fee. Long COVID clinics are disproportionately hospital-based, so this is often the applicable path, not the exception.",
    "hospital_outpatient_minimum_beneficiary_copay_usd": 76.25,
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=94621, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 8598,
    "cy2024_rendering_providers": 562,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_physician_payment_usd": 67.8,
    "facility_setting_total_rvu": 2.03,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 2.03 facility total RVUs on the modifier 26 line x $33.4009 = $67.80 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-test-cpet",
    "status": "PASS",
    "value_usd": 165.67,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 401.97,
      "evidence": "Avg_Sbmtd_Chrg = $401.97 on the National office row for 94621, alongside 8,598 services from 562 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 134.11,
      "evidence": "Avg_Mdcr_Alowd_Amt = $134.11 on the National office row for 94621, alongside 8,598 services from 562 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 67.8,
      "evidence": "2.03 facility total RVUs on the modifier 26 line for 94621 x $33.4009 = $67.80"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 94621",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "4.96 total non-facility RVUs x $33.4009 = $165.67",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-holter",
   "label": "Heart monitor worn for 48 hours (Holter)",
   "plain_language_synonyms": [
    "heart monitor",
    "Holter",
    "wore a monitor",
    "48 hour monitor",
    "heart rhythm monitor",
    "wore a heart monitor",
    "holter monitor",
    "24 hour monitor"
   ],
   "value_usd": 70.48,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "Ambulatory heart monitoring, ordered for the racing heart and palpitations common in long COVID. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 2.11 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $380.34 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one. This is the complete service. It can instead be billed as three separate pieces — the recording, the analysis, and the interpretation — which a ledger must not count on top of this one. Longer monitoring, seven to thirty days, uses different codes and costs substantially more. Hospitals do not bill this under the outpatient system at all.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 93224",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 380.34,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 68.1,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=93224, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 117189,
    "cy2024_rendering_providers": 6789,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-test-holter",
    "status": "PASS",
    "value_usd": 70.48,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 380.34,
      "evidence": "Avg_Sbmtd_Chrg = $380.34 on the National office row for 93224, alongside 117,189 services from 6,789 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 68.1,
      "evidence": "Avg_Mdcr_Alowd_Amt = $68.10 on the National office row for 93224, alongside 117,189 services from 6,789 providers"
     }
    ],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 93224",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "2.11 total non-facility RVUs x $33.4009 = $70.48",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-mh-psych-eval",
   "label": "First appointment with a psychiatrist (diagnostic evaluation)",
   "plain_language_synonyms": [
    "saw a psychiatrist",
    "mental health evaluation",
    "psychiatric evaluation",
    "sent me to psychiatry",
    "told me it was anxiety",
    "referred to mental health"
   ],
   "value_usd": 173.35,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The intake visit that frequently follows a normal workup, when a person is told their symptoms may be psychological. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 5.19 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $293.32 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one. Mental health is where a Medicare rate is least representative of reality. A large share of mental-health clinicians do not accept insurance at all, so many people pay full cash rates well above this figure and no claim is ever generated — which means no administrative dataset, including this one, can see that spending. In a hospital clinic the hospital adds $181.34.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 90791",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 293.32,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 144.74,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "hospital_outpatient_facility_fee_usd": 181.34,
    "hospital_outpatient_facility_fee_source": "CMS, January 2026 Hospital Outpatient Prospective Payment System Addendum B",
    "_opps_note": "If this happened inside a hospital-owned clinic or hospital department rather than a freestanding office, the hospital bills THIS fee in addition to the clinician's fee. Long COVID clinics are disproportionately hospital-based, so this is often the applicable path, not the exception.",
    "hospital_outpatient_minimum_beneficiary_copay_usd": 36.27,
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=90791, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 545302.8,
    "cy2024_rendering_providers": 70767,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_physician_payment_usd": 137.28,
    "facility_setting_total_rvu": 4.11,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 4.11 facility total RVUs x $33.4009 = $137.28. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-mh-psych-eval",
    "status": "PASS",
    "value_usd": 173.35,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 293.32,
      "evidence": "Avg_Sbmtd_Chrg = $293.32 on the National office row for 90791, alongside 545,302 services from 70,767 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 144.74,
      "evidence": "Avg_Mdcr_Alowd_Amt = $144.74 on the National office row for 90791, alongside 545,302 services from 70,767 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 137.28,
      "evidence": "4.11 facility total RVUs on the unmodified line for 90791 x $33.4009 = $137.28"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 90791",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "5.19 total non-facility RVUs x $33.4009 = $173.35",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-mh-therapy-45",
   "label": "Therapy session, 45 minutes",
   "plain_language_synonyms": [
    "therapy",
    "therapy session",
    "counseling",
    "saw a therapist",
    "talk therapy",
    "psychotherapy"
   ],
   "value_usd": 113.9,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The most commonly billed therapy session length. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.41 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $175.89 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one. Cash-pay therapy is common and invisible to claims data, so a ledger built only on this rate understates real spending for many people. In a hospital clinic the hospital adds a flat $181.34, the same fee whether the session is 30 minutes, an hour, or a full evaluation.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 90834",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 175.89,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 87.48,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "hospital_outpatient_facility_fee_usd": 181.34,
    "hospital_outpatient_facility_fee_source": "CMS, January 2026 Hospital Outpatient Prospective Payment System Addendum B",
    "_opps_note": "If this happened inside a hospital-owned clinic or hospital department rather than a freestanding office, the hospital bills THIS fee in addition to the clinician's fee. Long COVID clinics are disproportionately hospital-based, so this is often the applicable path, not the exception.",
    "hospital_outpatient_minimum_beneficiary_copay_usd": 36.27,
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=90834, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 3094068.1,
    "cy2024_rendering_providers": 63898,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_physician_payment_usd": 91.85,
    "facility_setting_total_rvu": 2.75,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 2.75 facility total RVUs x $33.4009 = $91.85. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-mh-therapy-45",
    "status": "PASS",
    "value_usd": 113.9,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 175.89,
      "evidence": "Avg_Sbmtd_Chrg = $175.89 on the National office row for 90834, alongside 3,094,068 services from 63,898 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 87.48,
      "evidence": "Avg_Mdcr_Alowd_Amt = $87.48 on the National office row for 90834, alongside 3,094,068 services from 63,898 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 91.85,
      "evidence": "2.75 facility total RVUs on the unmodified line for 90834 x $33.4009 = $91.85"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 90834",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.41 total non-facility RVUs x $33.4009 = $113.90",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-mh-therapy-60",
   "label": "Therapy session, 60 minutes",
   "plain_language_synonyms": [
    "hour of therapy",
    "hour long therapy",
    "60 minute session"
   ],
   "value_usd": 167,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The highest-volume therapy code in Medicare, at 6.7 million office sessions in 2024. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 5.0 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $207.77 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 90837",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 207.77,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 124.97,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "hospital_outpatient_facility_fee_usd": 181.34,
    "hospital_outpatient_facility_fee_source": "CMS, January 2026 Hospital Outpatient Prospective Payment System Addendum B",
    "_opps_note": "If this happened inside a hospital-owned clinic or hospital department rather than a freestanding office, the hospital bills THIS fee in addition to the clinician's fee. Long COVID clinics are disproportionately hospital-based, so this is often the applicable path, not the exception.",
    "hospital_outpatient_minimum_beneficiary_copay_usd": 36.27,
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=90837, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 6700424.7,
    "cy2024_rendering_providers": 87981,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_physician_payment_usd": 135.27,
    "facility_setting_total_rvu": 4.05,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 4.05 facility total RVUs x $33.4009 = $135.27. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-mh-therapy-60",
    "status": "PASS",
    "value_usd": 167,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 207.77,
      "evidence": "Avg_Sbmtd_Chrg = $207.77 on the National office row for 90837, alongside 6,700,424 services from 87,981 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 124.97,
      "evidence": "Avg_Mdcr_Alowd_Amt = $124.97 on the National office row for 90837, alongside 6,700,424 services from 87,981 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 135.27,
      "evidence": "4.05 facility total RVUs on the unmodified line for 90837 x $33.4009 = $135.27"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 90837",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "5.00 total non-facility RVUs x $33.4009 = $167.00",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "meps2022-longcovid-excess-total",
   "label": "THE HEADLINE — how much MORE a person with long COVID spends on health care in a year",
   "plain_language_synonyms": [
    "what long covid costs",
    "the extra cost of long covid",
    "how much more I spend",
    "cost of long covid",
    "yearly cost"
   ],
   "value_usd": 4098,
   "out_of_pocket_usd": null,
   "value_range_usd": [
    1619,
    6578
   ],
   "basis": "total_expenditure",
   "attribution": "excess",
   "summable": false,
   "mutually_exclusive_with": [
    "__ALL_PER_EVENT_LINES__"
   ],
   "bundles_ancillaries": true,
   "year": "2022",
   "geography": "United States, national",
   "population": "U.S. civilian noninstitutionalized adults 18 and older; 17,119 survey respondents standing for about 254 million adults, of whom 1,196 reported long COVID and 8,939 reported never having had COVID",
   "coverage_statement": "SHOW THIS AS A RANGE, NOT A NUMBER. $4,098 is the middle of an interval that runs from $1,619 to $6,578, and the interval is the honest answer. It is the EXCESS: the extra amount an adult reporting long COVID spent in a year over and above a comparable adult who never had COVID, after adjusting for age, income, insurance and other conditions. It is not the total they spent. That distinction is the whole point — the gross figure is $11,305 a year, but a comparable person without COVID already spends $7,162, so roughly 63 percent of the gross is care they would have needed anyway.\n\n🔴 THIS FIGURE CANNOT BE ADDED TO ANY VISIT, TEST OR SCAN IN THIS LEDGER. It already contains all of them. It is an alternative view of the same year, not another line in it.\n\nWho it describes: non-institutionalized U.S. adults in 2022, where long COVID means the person said yes to having had COVID and yes to symptoms lasting three months or more. Who it does NOT describe: children; people in nursing homes, prisons, or on active military duty; people who died, since the survey follows survivors and the sickest are therefore underrepresented. Note the definition carefully — long COVID here is SELF-REPORTED, not a U09.9 diagnosis code, so it includes people who never got a diagnosis. For a tool about invisible illness that is a strength, but it is a different population than a clinic-based cohort.\n\nWhat would make it wrong for you: a case much milder or much more severe than average (spending is extremely skewed), a hospitalization, or being uninsured — because spending measures the care you got, not the care you needed.\n\n🔴 WHERE IT COMES FROM, STATED PLAINLY: this is a peer-reviewed analysis OF a government survey, not a government statistic. AHRQ has published no long COVID cost estimate of its own. Its long COVID brief is prevalence only, with no dollar figures in it at all. We would rather tell you that than let a journal article read as a federal number.",
   "source_title": "Neba R, Pedaprolu LS, Neba B, Sambamoorthi U. Long COVID Is Associated with Excess Direct Healthcare Expenditures Among Adults in the United States. Healthcare (Basel) 2025;13(21):2704 — a peer-reviewed secondary analysis of MEPS 2022, NOT a government publication",
   "source_url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC12607343/",
   "confidence": "VERIFIED",
   "code": null,
   "alternates": {
    "cost_ratio": 1.54,
    "cost_ratio_ci95": [
     1.24,
     1.93
    ],
    "excess_paid_by_insurers_usd": 3705,
    "excess_paid_by_insurers_ci95": [
     1442,
     5968
    ],
    "gross_annual_spending_long_covid_usd": 11305.3,
    "gross_annual_spending_no_covid_usd": 7161.9,
    "gross_annual_spending_acute_covid_only_usd": 7668.8
   },
   "agency": "AHRQ",
   "agency_display": "AHRQ MEPS",
   "audit": {
    "id": "meps2022-longcovid-excess-total",
    "status": "PASS",
    "value_usd": 4098,
    "basis": "total_expenditure",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "AHRQ MEPS",
    "code": null,
    "loinc": null,
    "check": "read in the cited MEPS 2022 analysis",
    "evidence": "$4,098 with its 95% interval $1,619 to $6,578; the same figures on the Table 3 line, with the cost ratio 1.54; gross annual spending $11,305.3 long COVID against $7,161.9 no COVID; payer share of the excess, $3,705",
    "source_url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC12607343/",
    "source_key": "pmc",
    "extras": []
   }
  },
  {
   "id": "meps2022-longcovid-excess-out-of-pocket",
   "label": "How much more you personally pay — THE ANSWER IS: NOT DISTINGUISHABLE FROM ZERO",
   "plain_language_synonyms": [
    "what I paid out of pocket",
    "my share",
    "out of pocket cost of long covid",
    "what it cost me personally"
   ],
   "value_usd": null,
   "out_of_pocket_usd": null,
   "basis": "out_of_pocket",
   "attribution": "excess",
   "summable": false,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": true,
   "year": "2022",
   "geography": "United States, national",
   "population": "U.S. civilian noninstitutionalized adults 18 and older, MEPS 2022",
   "coverage_statement": "🔴 THIS IS A FINDING, NOT A MISSING NUMBER, AND IT IS THE MOST IMPORTANT THING IN THIS TOOL.\n\nThe best nationally representative U.S. evidence found NO statistically significant difference in out-of-pocket spending between adults with and without long COVID. The point estimate was $236 a year, but its confidence interval runs from MINUS $95 to PLUS $566 — it crosses zero, at p = 0.162. The authors state it directly: they did not observe significant differences in out-of-pocket expenditures.\n\nWe deliberately carry no dollar value in this field. A number in a value field gets rendered, and rendering $236 would assert something the source explicitly declines to assert.\n\nWhat the data DOES show is where the money went: of the $4,098 in excess spending, about $3,705 landed on insurers, not visibly on the patient's own wallet. That is the honest and uncomfortable finding — for the average insured adult, long COVID drives large excess spending that insurance absorbs. It does NOT mean individuals are not hit hard. An average hides the tail, and this estimate does not separate out people with high deductibles or no insurance at all, who are precisely the people for whom the null result is least likely to hold. It also cannot see care someone went without because they could not afford it, and it excludes insurance premiums entirely.\n\nWhy we lead with this rather than bury it: a ledger that headlines a big personal out-of-pocket number is not supported by the best national evidence. Saying so is the strongest proof we have that this tool reports what the data says rather than what would be more persuasive.",
   "source_title": "Neba R, Pedaprolu LS, Neba B, Sambamoorthi U. Long COVID Is Associated with Excess Direct Healthcare Expenditures Among Adults in the United States. Healthcare (Basel) 2025;13(21):2704 — a peer-reviewed secondary analysis of MEPS 2022, NOT a government publication",
   "source_url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC12607343/",
   "confidence": "VERIFIED",
   "code": null,
   "alternates": {
    "point_estimate_usd_DO_NOT_RENDER_ALONE": 236,
    "ci95": [
     -95,
     566
    ],
    "p_value": 0.162,
    "statistically_significant": false,
    "excess_borne_by_third_party_payers_usd": 3705,
    "gross_annual_out_of_pocket_long_covid_usd": 1322,
    "gross_annual_out_of_pocket_no_covid_usd": 1064.8
   },
   "agency": "AHRQ",
   "agency_display": "AHRQ MEPS",
   "audit": {
    "id": "meps2022-longcovid-excess-out-of-pocket",
    "status": "PASS",
    "value_usd": null,
    "basis": "out_of_pocket",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "AHRQ MEPS",
    "code": null,
    "loinc": null,
    "check": "read in the cited MEPS 2022 analysis (a null result)",
    "evidence": "the Table 3 out-of-pocket line: $236 excess, 95% CI -95 to 566, p = 0.162; the authors' own sentence that it is not significant",
    "source_url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC12607343/",
    "source_key": "pmc",
    "extras": []
   }
  },
  {
   "id": "meps2018-retail-rx-out-of-pocket",
   "label": "What you pay out of pocket for prescriptions in a year",
   "plain_language_synonyms": [
    "prescriptions",
    "my medications",
    "pharmacy",
    "drug costs",
    "medicine",
    "copays for my meds",
    "what I pay for prescriptions"
   ],
   "value_usd": 54,
   "out_of_pocket_usd": 54,
   "basis": "out_of_pocket",
   "attribution": "gross",
   "summable": false,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2018",
   "geography": "United States, national",
   "population": "U.S. civilian noninstitutionalized people who filled at least one retail prescription during the year",
   "coverage_statement": "🔴 THIS IS AN ANNUAL FIGURE AND CANNOT BE ADDED TO THE PER-VISIT LINES IN THIS LEDGER — different time unit, different basis. It is shown beside them, not inside the sum.\n\nThis is a MEDIAN, not an average: half of people who filled any prescription paid less than $54 out of pocket for the whole year, half paid more. The distribution is very skewed, and for a long-term illness with several medications the tail is the relevant part: the top five percent paid at least $945, and elderly adults with no drug coverage paid $1,624.\n\nWhat it does NOT cover: anything given to you in a clinic, in a doctor's office, or during a hospital stay. Infusions and in-office injections are absent entirely. It would be wrong for anyone on a brand-only or specialty drug, where annual out-of-pocket can exceed this many times over, and for anyone uninsured.\n\nIt is in 2018 dollars because AHRQ has not published a newer version of this report. We show the published number with its date rather than inflating it forward, because inflating it would make it ours.\n\nA note specific to long COVID: there is no approved drug therapy, and much of what is prescribed — low-dose naltrexone, beta blockers, antihistamines, salt tablets, compounded formulations — is off-label, generic, or not covered, so it may never generate an insurance claim at all and would be invisible to every claims-based source.",
   "source_title": "AHRQ, MEPS Statistical Brief #532: Out-of-Pocket Spending for Retail Prescribed Drugs by Age and Type of Prescription Drug Coverage, 2009 to 2018 (December 2020)",
   "source_url": "https://meps.ahrq.gov/data_files/publications/st532/stat532.pdf",
   "confidence": "VERIFIED",
   "code": null,
   "alternates": {
    "p95_annual_out_of_pocket_usd": 945,
    "elderly_no_drug_coverage_p95_usd": 1624,
    "uninsured_nonelderly_p95_usd": 1620
   },
   "agency": "AHRQ",
   "agency_display": "AHRQ MEPS",
   "audit": {
    "id": "meps2018-retail-rx-out-of-pocket",
    "status": "PASS",
    "value_usd": 54,
    "basis": "out_of_pocket",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "AHRQ MEPS",
    "code": null,
    "loinc": null,
    "check": "read in the cited report",
    "evidence": "median out-of-pocket spending for drugs among all individuals who purchased at least one drug was $93, and this fell to $54 in 2018",
    "source_url": "https://meps.ahrq.gov/data_files/publications/st532/stat532.pdf",
    "source_key": "st532",
    "extras": [
     {
      "label": "p95 $945",
      "ok": true,
      "evidence": "95th percentile fell from $1,369 to $945"
     }
    ]
   }
  },
  {
   "id": "meps2014-office-visit-any",
   "label": "The same office visit, measured as what everyone actually PAID (2014)",
   "plain_language_synonyms": [
    "what a doctor visit really costs",
    "average doctor visit"
   ],
   "value_usd": 190,
   "out_of_pocket_usd": 28,
   "basis": "payment",
   "attribution": "gross",
   "summable": false,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": true,
   "year": "2014",
   "geography": "United States, national",
   "population": "U.S. civilian noninstitutionalized population, all ages",
   "coverage_statement": "An alternative view of an office visit, on a different basis than the Medicare rates above. This is the average of what ALL payers combined actually PAID for one visit — you, your insurer, Medicare, Medicaid, workers' compensation — not what was billed and not a fee schedule. It blends a two-minute nurse recheck with a long complex consultation.\n\n⚠️ ABOUT THE $28 OUT-OF-POCKET FIGURE: it averages in the majority of visits where the patient paid nothing at all, so it is not a copay and it is not what a person with a deductible sees. The companion report shows that only 48 percent of physician office visits generated any patient payment, and among those that did the average was $61. If you know you paid something, $61 is the honest figure for you, not $29. Who it describes: people living in households. Who it does NOT describe: anyone in a nursing home, a prison, or on active military duty, and it is not adjusted for who you are — it blends every insurance status together. It would be wrong for you if you are uninsured and paying cash, since cash prices are typically far above negotiated payments.\n\n🔴 THIS FIGURE ALREADY INCLUDES the blood work, imaging and other services ordered during the visit. MEPS folds them into the visit's total and never itemizes them, so a lab or scan must NOT be added on top of this one. That is the opposite of how the Medicare fee-schedule lines in this ledger work, where labs and imaging are separately billed and can legitimately be added. There is no single rule; it depends on the source.\n\n🔴 READ THE YEAR. AHRQ stopped publishing these per-visit tables after 2014. We checked: the 2015 and 2016 files return 404, and the data moved into an interactive dashboard whose settings cannot be reached from a fixed web address, so no newer per-visit table can be cited at a link a stranger can open. About a decade of medical price growth sits between this figure and today. We show the published number with its date rather than inflating it forward — inflating it would make the number ours instead of the government's.",
   "source_title": "AHRQ, MEPS Household Component Summary Table 1: Total Utilization and Mean Expenses per Visit by Type of Ambulatory Health Care Service, 2014",
   "source_url": "https://meps.ahrq.gov/data_stats/summ_tables/hc/mean_expend/2014/table1.pdf",
   "confidence": "VERIFIED",
   "code": null,
   "alternates": {
    "standard_error_total_usd": 2.9,
    "standard_error_out_of_pocket_usd": 0.8,
    "physician_visits_only_total_usd": 228,
    "physician_visits_only_median_total_usd": 108,
    "physician_visits_only_out_of_pocket_conditional_on_paying_usd": 61,
    "share_of_visits_with_any_patient_payment_pct": 48,
    "_mean_vs_median_note": "The mean physician visit is $228 but the MEDIAN is $108 — less than half. The mean is dragged up by a small tail of very expensive visits, so it is not the typical visit and should never be presented to a patient as what a visit costs. 2013 data."
   },
   "agency": "AHRQ",
   "agency_display": "AHRQ MEPS",
   "audit": {
    "id": "meps2014-office-visit-any",
    "status": "PASS",
    "value_usd": 190,
    "basis": "payment",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "AHRQ MEPS",
    "code": null,
    "loinc": null,
    "check": "read in the cited table",
    "evidence": "All visits 1,876.37 52.86 $190 $2.9 $28 $0.8",
    "source_url": "https://meps.ahrq.gov/data_stats/summ_tables/hc/mean_expend/2014/table1.pdf",
    "source_key": "meps2014t1",
    "extras": []
   }
  },
  {
   "id": "meps2014-ed-visit",
   "label": "The same ER visit, measured as what everyone actually PAID (2014)",
   "plain_language_synonyms": [
    "what an ER visit really costs",
    "average emergency room cost"
   ],
   "value_usd": 1048,
   "out_of_pocket_usd": 95,
   "basis": "payment",
   "attribution": "gross",
   "summable": false,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": true,
   "year": "2014",
   "geography": "United States, national",
   "population": "U.S. civilian noninstitutionalized population, all ages",
   "coverage_statement": "Total payments from all sources for one emergency department visit where the patient was sent home. \n\n🔴 THE EXCLUSION IS LOAD-BEARING: if the visit ended in a hospital admission, its cost is counted in the inpatient figures instead. So this UNDERSTATES exactly the ER visits that went worst.\n\nThe $95 out-of-pocket figure averages in every visit where the patient paid nothing. It does not describe an uninsured person or someone early in a deductible year, both of whom routinely pay many multiples of it. Who it describes: people living in households. Who it does NOT describe: anyone in a nursing home, a prison, or on active military duty, and it is not adjusted for who you are — it blends every insurance status together. It would be wrong for you if you are uninsured and paying cash, since cash prices are typically far above negotiated payments.\n\n🔴 THIS FIGURE ALREADY INCLUDES the blood work, imaging and other services ordered during the visit. MEPS folds them into the visit's total and never itemizes them, so a lab or scan must NOT be added on top of this one. That is the opposite of how the Medicare fee-schedule lines in this ledger work, where labs and imaging are separately billed and can legitimately be added. There is no single rule; it depends on the source.\n\n🔴 READ THE YEAR. AHRQ stopped publishing these per-visit tables after 2014. We checked: the 2015 and 2016 files return 404, and the data moved into an interactive dashboard whose settings cannot be reached from a fixed web address, so no newer per-visit table can be cited at a link a stranger can open. About a decade of medical price growth sits between this figure and today. We show the published number with its date rather than inflating it forward — inflating it would make the number ours instead of the government's.",
   "source_title": "AHRQ, MEPS Household Component Summary Table 1, 2014",
   "source_url": "https://meps.ahrq.gov/data_stats/summ_tables/hc/mean_expend/2014/table1.pdf",
   "confidence": "VERIFIED",
   "code": null,
   "alternates": {
    "standard_error_total_usd": 40.3,
    "standard_error_out_of_pocket_usd": 6.8
   },
   "agency": "AHRQ",
   "agency_display": "AHRQ MEPS",
   "audit": {
    "id": "meps2014-ed-visit",
    "status": "PASS",
    "value_usd": 1048,
    "basis": "payment",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "AHRQ MEPS",
    "code": null,
    "loinc": null,
    "check": "read in the cited table",
    "evidence": "61.28 1.95 $1,048 $40.3 $95 $6.8",
    "source_url": "https://meps.ahrq.gov/data_stats/summ_tables/hc/mean_expend/2014/table1.pdf",
    "source_key": "meps2014t1",
    "extras": []
   }
  },
  {
   "id": "meps2014-hospital-outpatient",
   "label": "A visit in a HOSPITAL clinic, measured as what everyone actually PAID (2014)",
   "plain_language_synonyms": [
    "hospital clinic visit",
    "outpatient department"
   ],
   "value_usd": 927,
   "out_of_pocket_usd": 54,
   "basis": "payment",
   "attribution": "gross",
   "summable": false,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": true,
   "year": "2014",
   "geography": "United States, national",
   "population": "U.S. civilian noninstitutionalized population, all ages",
   "coverage_statement": "The single most useful fact in this table for a patient: a visit in a HOSPITAL outpatient department cost about five times a same-sounding visit in a doctor's office ($927 against $190). The site of service, not the service, drove the price. It does not describe office-based care. Who it describes: people living in households. Who it does NOT describe: anyone in a nursing home, a prison, or on active military duty, and it is not adjusted for who you are — it blends every insurance status together. It would be wrong for you if you are uninsured and paying cash, since cash prices are typically far above negotiated payments.\n\n🔴 THIS FIGURE ALREADY INCLUDES the blood work, imaging and other services ordered during the visit. MEPS folds them into the visit's total and never itemizes them, so a lab or scan must NOT be added on top of this one. That is the opposite of how the Medicare fee-schedule lines in this ledger work, where labs and imaging are separately billed and can legitimately be added. There is no single rule; it depends on the source.\n\n🔴 READ THE YEAR. AHRQ stopped publishing these per-visit tables after 2014. We checked: the 2015 and 2016 files return 404, and the data moved into an interactive dashboard whose settings cannot be reached from a fixed web address, so no newer per-visit table can be cited at a link a stranger can open. About a decade of medical price growth sits between this figure and today. We show the published number with its date rather than inflating it forward — inflating it would make the number ours instead of the government's.",
   "source_title": "AHRQ, MEPS Household Component Summary Table 1, 2014",
   "source_url": "https://meps.ahrq.gov/data_stats/summ_tables/hc/mean_expend/2014/table1.pdf",
   "confidence": "VERIFIED",
   "code": null,
   "alternates": {
    "standard_error_total_usd": 58,
    "standard_error_out_of_pocket_usd": 3.8
   },
   "agency": "AHRQ",
   "agency_display": "AHRQ MEPS",
   "audit": {
    "id": "meps2014-hospital-outpatient",
    "status": "PASS",
    "value_usd": 927,
    "basis": "payment",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "AHRQ MEPS",
    "code": null,
    "loinc": null,
    "check": "read in the cited table",
    "evidence": "All visits 167.82 9.39 $927 $58.0 $54 $3.8",
    "source_url": "https://meps.ahrq.gov/data_stats/summ_tables/hc/mean_expend/2014/table1.pdf",
    "source_key": "meps2014t1",
    "extras": []
   }
  },
  {
   "id": "meps2013-primary-care-visit",
   "label": "A primary-care visit, measured as what everyone actually PAID (2013)",
   "plain_language_synonyms": [
    "primary care cost",
    "what my regular doctor costs"
   ],
   "value_usd": 166,
   "out_of_pocket_usd": 22,
   "basis": "payment",
   "attribution": "gross",
   "summable": false,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": true,
   "year": "2013",
   "geography": "United States, national",
   "population": "U.S. civilian noninstitutionalized population, all ages",
   "coverage_statement": "The entry point of nearly every diagnostic odyssey — general practice, family practice and internal medicine together were 34.4 percent of all physician office visits. This does NOT separate a ten-minute recheck from a forty-minute workup: MEPS does not code visits by level of service, so there is no 99213-versus-99214 distinction available anywhere in this source. That is why the Medicare fee schedule carries those lines in this tool instead. About 52 percent of primary-care visits generated any patient payment, a higher share than most specialties. Who it describes: people living in households. Who it does NOT describe: anyone in a nursing home, a prison, or on active military duty, and it is not adjusted for who you are — it blends every insurance status together. It would be wrong for you if you are uninsured and paying cash, since cash prices are typically far above negotiated payments.\n\n🔴 THIS FIGURE ALREADY INCLUDES the blood work, imaging and other services ordered during the visit. MEPS folds them into the visit's total and never itemizes them, so a lab or scan must NOT be added on top of this one. That is the opposite of how the Medicare fee-schedule lines in this ledger work, where labs and imaging are separately billed and can legitimately be added. There is no single rule; it depends on the source.\n\n🔴 READ THE YEAR. AHRQ stopped publishing these per-visit tables after 2014. We checked: the 2015 and 2016 files return 404, and the data moved into an interactive dashboard whose settings cannot be reached from a fixed web address, so no newer per-visit table can be cited at a link a stranger can open. About a decade of medical price growth sits between this figure and today. We show the published number with its date rather than inflating it forward — inflating it would make the number ours instead of the government's.",
   "source_title": "AHRQ, MEPS Statistical Brief #484: Expenses for Office-Based Physician Visits by Specialty, 2013",
   "source_url": "https://meps.ahrq.gov/data_files/publications/st484/stat484.pdf",
   "confidence": "VERIFIED",
   "code": null,
   "alternates": null,
   "agency": "AHRQ",
   "agency_display": "AHRQ MEPS",
   "audit": {
    "id": "meps2013-primary-care-visit",
    "status": "PASS",
    "value_usd": 166,
    "basis": "payment",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "AHRQ MEPS",
    "code": null,
    "loinc": null,
    "check": "read in the cited report",
    "evidence": "means for primary care providers (general practitioners, family practitioners, and internists), pediatricians, and psychiatrists The overall mean out-of- of $166, $161, and $143, respectively, were below the national ave",
    "source_url": "https://meps.ahrq.gov/data_files/publications/st484/stat484.pdf",
    "source_key": "st484",
    "extras": []
   }
  },
  {
   "id": "meps2013-psychiatry-visit",
   "label": "A psychiatrist visit, measured as what everyone actually PAID (2013)",
   "plain_language_synonyms": [
    "psychiatrist cost",
    "what psychiatry costs"
   ],
   "value_usd": 143,
   "out_of_pocket_usd": 26,
   "basis": "payment",
   "attribution": "gross",
   "summable": false,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": true,
   "year": "2013",
   "geography": "United States, national",
   "population": "U.S. civilian noninstitutionalized population, all ages",
   "coverage_statement": "The LOWEST-paid of the eight named specialties — a psychiatrist visit was paid less than a primary-care visit. This matters for a long COVID ledger because psychiatric referral is a common terminus of a negative workup. It covers visits to PSYCHIATRISTS (medical doctors) ONLY: it does not cover psychologists, licensed clinical social workers, therapists or counselors, who deliver most talk therapy in the United States. The $26 out-of-pocket badly understates the real experience, because psychiatrists have unusually low insurance participation and cash arrangements are common. Who it describes: people living in households. Who it does NOT describe: anyone in a nursing home, a prison, or on active military duty, and it is not adjusted for who you are — it blends every insurance status together. It would be wrong for you if you are uninsured and paying cash, since cash prices are typically far above negotiated payments.\n\n🔴 THIS FIGURE ALREADY INCLUDES the blood work, imaging and other services ordered during the visit. MEPS folds them into the visit's total and never itemizes them, so a lab or scan must NOT be added on top of this one. That is the opposite of how the Medicare fee-schedule lines in this ledger work, where labs and imaging are separately billed and can legitimately be added. There is no single rule; it depends on the source.\n\n🔴 READ THE YEAR. AHRQ stopped publishing these per-visit tables after 2014. We checked: the 2015 and 2016 files return 404, and the data moved into an interactive dashboard whose settings cannot be reached from a fixed web address, so no newer per-visit table can be cited at a link a stranger can open. About a decade of medical price growth sits between this figure and today. We show the published number with its date rather than inflating it forward — inflating it would make the number ours instead of the government's.",
   "source_title": "AHRQ, MEPS Statistical Brief #484",
   "source_url": "https://meps.ahrq.gov/data_files/publications/st484/stat484.pdf",
   "confidence": "VERIFIED",
   "code": null,
   "alternates": null,
   "agency": "AHRQ",
   "agency_display": "AHRQ MEPS",
   "audit": {
    "id": "meps2013-psychiatry-visit",
    "status": "PASS",
    "value_usd": 143,
    "basis": "payment",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "AHRQ MEPS",
    "code": null,
    "loinc": null,
    "check": "read in the cited report",
    "evidence": "pediatricians, and psychiatrists The overall mean out-of- of $166, $161, and $143",
    "source_url": "https://meps.ahrq.gov/data_files/publications/st484/stat484.pdf",
    "source_key": "st484",
    "extras": []
   }
  },
  {
   "id": "meps2013-cardiology-visit",
   "label": "A cardiology visit, measured as what everyone actually PAID (2013)",
   "plain_language_synonyms": [
    "cardiologist cost",
    "heart doctor cost"
   ],
   "value_usd": 303,
   "out_of_pocket_usd": 23,
   "basis": "payment",
   "attribution": "gross",
   "summable": false,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": true,
   "year": "2013",
   "geography": "United States, national",
   "population": "U.S. civilian noninstitutionalized population, all ages",
   "coverage_statement": "One of the specialist consults a long COVID patient commonly receives, for palpitations, POTS-like symptoms or chest pain. This is the VISIT ONLY — any echocardiogram, monitor or tilt-table test performed is priced separately and MEPS does not itemize them. The $23 out-of-pocket is low because only 40.8 percent of cardiology visits generated any patient payment at all: cardiology patients skew older and Medicare-covered. It does NOT describe a working-age long COVID patient on a commercial high-deductible plan, which is precisely who this tool is built for and who would pay far more. Who it describes: people living in households. Who it does NOT describe: anyone in a nursing home, a prison, or on active military duty, and it is not adjusted for who you are — it blends every insurance status together. It would be wrong for you if you are uninsured and paying cash, since cash prices are typically far above negotiated payments.\n\n🔴 THIS FIGURE ALREADY INCLUDES the blood work, imaging and other services ordered during the visit. MEPS folds them into the visit's total and never itemizes them, so a lab or scan must NOT be added on top of this one. That is the opposite of how the Medicare fee-schedule lines in this ledger work, where labs and imaging are separately billed and can legitimately be added. There is no single rule; it depends on the source.\n\n🔴 READ THE YEAR. AHRQ stopped publishing these per-visit tables after 2014. We checked: the 2015 and 2016 files return 404, and the data moved into an interactive dashboard whose settings cannot be reached from a fixed web address, so no newer per-visit table can be cited at a link a stranger can open. About a decade of medical price growth sits between this figure and today. We show the published number with its date rather than inflating it forward — inflating it would make the number ours instead of the government's.",
   "source_title": "AHRQ, MEPS Statistical Brief #484",
   "source_url": "https://meps.ahrq.gov/data_files/publications/st484/stat484.pdf",
   "confidence": "VERIFIED",
   "code": null,
   "alternates": null,
   "agency": "AHRQ",
   "agency_display": "AHRQ MEPS",
   "audit": {
    "id": "meps2013-cardiology-visit",
    "status": "PASS",
    "value_usd": 303,
    "basis": "payment",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "AHRQ MEPS",
    "code": null,
    "loinc": null,
    "check": "read in the cited report",
    "evidence": "cardiologists ($303)",
    "source_url": "https://meps.ahrq.gov/data_files/publications/st484/stat484.pdf",
    "source_key": "st484",
    "extras": []
   }
  },
  {
   "id": "hcup2021-ed-facility-cost",
   "label": "What it COST THE HOSPITAL to provide one ER visit (a different kind of number again)",
   "plain_language_synonyms": [
    "what the hospital spent",
    "hospital cost of an ER visit"
   ],
   "value_usd": 750,
   "out_of_pocket_usd": null,
   "basis": "facility_cost",
   "attribution": "gross",
   "summable": false,
   "mutually_exclusive_with": [
    "cms-ed-99284-complete",
    "meps2014-ed-visit"
   ],
   "bundles_ancillaries": true,
   "year": "2021",
   "geography": "United States, national estimate",
   "population": "All 107.4 million treat-and-release emergency department visits, all payers, all ages, across 40 partner states covering 74.1 percent of the U.S. population",
   "coverage_statement": "🔴 A SIXTH KIND OF NUMBER. This is not a charge, not an allowed amount, not a payment, and not out-of-pocket. It is AHRQ's estimate of what the hospital SPENT — wages, supplies, utilities — to produce one ER visit that did not end in admission. AHRQ says so itself: charges 'do not reflect how much hospital services cost or the specific amounts that hospitals received in payment.' We gave it its own basis label rather than force it into an existing one, because collapsing it into 'charge' is exactly the error this product exists to prevent.\n\nIt EXCLUDES the physician's separate bill by design, so every figure of this kind understates the total bill. It does not describe freestanding emergency rooms, urgent care, or visits ending in admission. It is not what anyone paid.\n\nBy age: $440 for children, $660 for adults 18–44, $880 for 45–64, $1,110 for 65 and older. By expected payer: $600 Medicaid, $790 private, $1,040 Medicare, $610 self-pay. Read the Medicaid-versus-Medicare gap carefully — it reflects a younger, less complex Medicaid ER population, NOT a discount on the same service.\n\n🔴 A STRUCTURAL LIMIT WORTH KNOWING: this database records visits, not people. It has no patient identifier, so it can never follow one person across visits — not with more effort, not with a data-use agreement, not at all. It can say what an average ER visit costs; it can never say what one person's eleven visits cost. Any per-person total built from it is an assembled average, never an observed journey.\n\nThe newest published national ER cost figure is this 2021 one. For scale, it was $530 in 2017 — a 41.5 percent rise in four years, which is a warning that any dated figure here understates today.",
   "source_title": "AHRQ, HCUP Statistical Brief #311: Costs of Treat-and-Release Emergency Department Visits in the United States, 2021 (September 2024)",
   "source_url": "https://hcup-us.ahrq.gov/reports/statbriefs/sb311-ED-visit-costs-2021.pdf",
   "confidence": "VERIFIED",
   "code": null,
   "alternates": {
    "age_0_17_usd": 440,
    "age_18_44_usd": 660,
    "age_45_64_usd": 880,
    "age_65_plus_usd": 1110,
    "payer_medicaid_usd": 600,
    "payer_private_usd": 790,
    "payer_medicare_usd": 1040,
    "payer_self_pay_usd": 610,
    "routine_discharge_usd": 710,
    "transferred_usd": 1560,
    "prior_year_2017_usd": 530
   },
   "agency": "AHRQ",
   "agency_display": "AHRQ HCUP",
   "audit": {
    "id": "hcup2021-ed-facility-cost",
    "status": "PASS",
    "value_usd": 750,
    "basis": "facility_cost",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "AHRQ HCUP",
    "code": null,
    "loinc": null,
    "check": "read in the cited report",
    "evidence": "average cost per visit of $750",
    "source_url": "https://hcup-us.ahrq.gov/reports/statbriefs/sb311-ED-visit-costs-2021.pdf",
    "source_key": "sb311",
    "extras": [
     {
      "label": "age split $440 / $1,110",
      "ok": true,
      "evidence": "average cost was $440 for children and $1,110 for"
     },
     {
      "label": "aggregate $80.3B",
      "ok": true,
      "evidence": "aggregate costs for ED visits totaled $80.3 billion"
     }
    ]
   }
  },
  {
   "id": "hcup2021-ed-cost-to-charge-ratio",
   "label": "How far a hospital's BILL sits above its cost (a ratio, not a dollar figure)",
   "plain_language_synonyms": [
    "why is my bill so high",
    "the bill versus the cost",
    "markup"
   ],
   "value_usd": null,
   "out_of_pocket_usd": null,
   "basis": "ratio",
   "attribution": "not_applicable",
   "summable": false,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2021",
   "geography": "United States, 993 hospital-owned emergency departments",
   "population": "Hospital-level all-payer emergency department cost-to-charge ratios",
   "coverage_statement": "Carried deliberately with NO dollar value, because it is a ratio. The average hospital's estimated ER cost is about 21 cents per dollar it bills — billed charges run roughly five times production cost. The 2023 figure is 0.20, so the gap is stable and slightly widening. The spread across hospitals is enormous: from 0.02 to 1.49, meaning at one hospital charges are about fifty times cost while at another they are below it.\n\nThis single ratio is what lets this tool show you one ER visit as three different numbers on three different bases and cite all three.\n\n🔴 A PROHIBITION RECORDED HERE ON PURPOSE, SO NOBODY REDISCOVERS IT INNOCENTLY: do NOT divide the $750 average cost by 0.21 to produce a $3,571 'average ER charge.' It is arithmetically invalid — the mean of hospital-level ratios is not the ratio of national means — and no source publishes that number. It is tempting because it would make an excellent headline. It is still wrong, and we are not publishing it.\n\nIt describes hospital-level conversion factors. It does not describe any individual's bill, any insurer's allowed amount, or a discount anyone can negotiate.",
   "source_title": "AHRQ, HCUP Summary Statistics for the Cost-to-Charge Ratio Files for the NEDS, 2021 and 2023",
   "source_url": "https://hcup-us.ahrq.gov/db/ccr/ed-ccr/SummaryStats_edcc2021neds.PDF",
   "confidence": "VERIFIED",
   "code": null,
   "alternates": {
    "mean_ratio_2021": 0.21,
    "mean_ratio_2023": 0.2,
    "min_2021": 0.02,
    "max_2021": 1.49,
    "std_dev_2021": 0.14,
    "n_hospitals_2021": 993
   },
   "agency": "AHRQ",
   "agency_display": "AHRQ HCUP",
   "audit": {
    "id": "hcup2021-ed-cost-to-charge-ratio",
    "status": "PASS",
    "value_usd": null,
    "basis": "ratio",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "AHRQ HCUP",
    "code": null,
    "loinc": null,
    "check": "all-payer ED cost-to-charge ratio, 2021",
    "evidence": "N=993 hospitals, min 0.02, max 1.49, mean 0.21, SD 0.14 — read on the summary line",
    "source_url": "https://hcup-us.ahrq.gov/db/ccr/ed-ccr/SummaryStats_edcc2021neds.PDF",
    "source_key": "edccr",
    "extras": []
   }
  },
  {
   "id": "meps2022-benchmark-heart-disease",
   "label": "BENCHMARK — what a year of treated heart disease costs",
   "plain_language_synonyms": [
    "compared to heart disease",
    "how does this compare"
   ],
   "value_usd": 4900,
   "out_of_pocket_usd": null,
   "basis": "total_expenditure",
   "attribution": "gross",
   "summable": false,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": true,
   "year": "2022",
   "geography": "United States, national",
   "population": "U.S. civilian noninstitutionalized adults 18+ treated for heart disease (7.8 percent of adults)",
   "coverage_statement": "Here as a yardstick, and it is the most persuasive honest comparison in this dataset: a named, visible, well-funded chronic condition costs about the same per year ($4,900) as the EXCESS attributable to long COVID ($4,098). An invisible illness carrying a named disease's price tag.\n\n⚠️ The MEDIAN for the same population is $660 — the mean is more than seven times the median. Most people with treated heart disease spend far less than $4,900 and a few spend enormously more. Show both or show the median; the mean describes almost nobody.\n\nCondition-attributed spending only. Excludes lost productivity entirely.",
   "source_title": "AHRQ, MEPS Statistical Brief #562: Healthcare Expenditures for Heart Disease among Adults Aged 18 and Older, 2022 (July 2025)",
   "source_url": "https://meps.ahrq.gov/data_files/publications/st562/stat562.pdf",
   "confidence": "VERIFIED",
   "code": null,
   "alternates": {
    "median_usd": 660
   },
   "agency": "AHRQ",
   "agency_display": "AHRQ MEPS",
   "audit": {
    "id": "meps2022-benchmark-heart-disease",
    "status": "PASS",
    "value_usd": 4900,
    "basis": "total_expenditure",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "AHRQ MEPS",
    "code": null,
    "loinc": null,
    "check": "read in the cited report",
    "evidence": "$4,900 per adult",
    "source_url": "https://meps.ahrq.gov/data_files/publications/st562/stat562.pdf",
    "source_key": "st562",
    "extras": [
     {
      "label": "median $660",
      "ok": true,
      "evidence": "median of $660"
     }
    ]
   }
  },
  {
   "id": "meps2022-benchmark-diabetes",
   "label": "BENCHMARK — what a year of treated diabetes costs",
   "plain_language_synonyms": [
    "compared to diabetes"
   ],
   "value_usd": 5810,
   "out_of_pocket_usd": null,
   "basis": "total_expenditure",
   "attribution": "gross",
   "summable": false,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": true,
   "year": "2021-2022",
   "geography": "United States, national",
   "population": "U.S. civilian noninstitutionalized adults 18+ treated for diabetes (10.2 percent, ~26.3 million)",
   "coverage_statement": "A second yardstick, again close to the long COVID excess. Note what drives it: 80.3 percent of diabetes spending is prescription medications. That is precisely why a condition with NO approved drug therapy — long COVID — can devastate someone and still generate less measured spending than diabetes. Measured spending is not the same as burden.\n\nAHRQ states explicitly that these estimates exclude indirect costs such as lost productivity, and exclude complication care such as related emergency and hospital use, so they are not comparable to broader cost-of-illness estimates. Excludes nursing-home residents. Would be wrong for anyone on insulin or with complications.",
   "source_title": "AHRQ, MEPS Statistical Brief #568: Healthcare Expenditures for Diabetes Among Adults Aged 18 and Older, 2021-2022 (December 2025)",
   "source_url": "https://meps.ahrq.gov/data_files/publications/st568/stat568.pdf",
   "confidence": "VERIFIED",
   "code": null,
   "alternates": null,
   "agency": "AHRQ",
   "agency_display": "AHRQ MEPS",
   "audit": {
    "id": "meps2022-benchmark-diabetes",
    "status": "PASS",
    "value_usd": 5810,
    "basis": "total_expenditure",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "AHRQ MEPS",
    "code": null,
    "loinc": null,
    "check": "read in the cited report",
    "evidence": "$5,810 per adult with treated diabetes",
    "source_url": "https://meps.ahrq.gov/data_files/publications/st568/stat568.pdf",
    "source_key": "st568",
    "extras": []
   }
  },
  {
   "id": "meps2022-population-baseline",
   "label": "BASELINE — what an average American spends on health care in a year",
   "plain_language_synonyms": [
    "average person",
    "compared to everyone else",
    "national average"
   ],
   "value_usd": 6765,
   "out_of_pocket_usd": null,
   "basis": "total_expenditure",
   "attribution": "gross",
   "summable": false,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": true,
   "year": "2022",
   "geography": "United States, national",
   "population": "The entire U.S. civilian noninstitutionalized population, all ages",
   "coverage_statement": "🔴 SHOW THE DISTRIBUTION, NOT THIS MEAN. Spending is so concentrated that $6,765 describes almost nobody: the top 1 percent averaged $147,071, the top 5 percent $67,321, the top 10 percent $44,595, the top half $13,158, and the bottom half just $374. Presenting the mean as 'typical' would be misleading; the median person is far below it.\n\nExcludes nursing-home residents, incarcerated people, and active-duty military.\n\n🔴 A DERIVATION WE REFUSE TO MAKE: out-of-pocket was 13.6 percent of total spending in 2022. Do NOT multiply that share by $6,765 and present the product as a published average out-of-pocket figure. It would be our arithmetic, not a government estimate, and the share is regressive anyway — 26.2 percent for the bottom half of spenders against 8.0 percent for the top 5 percent.",
   "source_title": "AHRQ, MEPS Statistical Brief #560: Concentration of Healthcare Expenditures and Selected Characteristics of People with High Expenses, 2018-2022 (March 2025)",
   "source_url": "https://meps.ahrq.gov/data_files/publications/st560/stat560.pdf",
   "confidence": "VERIFIED",
   "code": null,
   "alternates": {
    "top_1pct_usd": 147071,
    "top_5pct_usd": 67321,
    "top_10pct_usd": 44595,
    "top_50pct_usd": 13158,
    "bottom_50pct_usd": 374,
    "out_of_pocket_share_pct": 13.6,
    "out_of_pocket_share_bottom_50pct": 26.2,
    "out_of_pocket_share_top_5pct": 8
   },
   "agency": "AHRQ",
   "agency_display": "AHRQ MEPS",
   "audit": {
    "id": "meps2022-population-baseline",
    "status": "PASS",
    "value_usd": 6765,
    "basis": "total_expenditure",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "AHRQ MEPS",
    "code": null,
    "loinc": null,
    "check": "read in the cited report",
    "evidence": "2022 $147,071 $67,321 $44,595 $13,158 $374 $6,765",
    "source_url": "https://meps.ahrq.gov/data_files/publications/st560/stat560.pdf",
    "source_key": "st560",
    "extras": []
   }
  },
  {
   "id": "cms2026-part-b-deductible",
   "label": "Medicare Part B annual deductible",
   "plain_language_synonyms": [
    "deductible",
    "my deductible",
    "before insurance kicks in"
   ],
   "value_usd": 283,
   "out_of_pocket_usd": 283,
   "basis": "out_of_pocket",
   "attribution": "not_applicable",
   "summable": false,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national and uniform",
   "population": "All Medicare Part B beneficiaries",
   "coverage_statement": "What a Medicare beneficiary pays before Part B cost-sharing begins, up from $257 in 2025. It is the gate on every physician, imaging, emergency and testing figure in this ledger — but NOT on laboratory tests, which carry no deductible at all.\n\nIt would be wrong for you if you have Medicaid, a Medigap plan that pays the deductible, or retiree coverage that does — in which case your effective deductible is zero. And it does not apply at all to anyone under 65 without a disability or kidney-failure entitlement, which is to say most people with long COVID. A commercial deductible is set by an employer or insurer and bears no relation to this number.",
   "source_title": "CMS, 2026 Medicare Parts A & B Premiums and Deductibles (fact sheet)",
   "source_url": "https://www.cms.gov/newsroom/fact-sheets/2026-medicare-parts-b-premiums-deductibles",
   "confidence": "VERIFIED",
   "code": null,
   "alternates": {
    "coinsurance_rate_after_deductible": 0.2,
    "standard_monthly_premium_usd": 202.9,
    "example_coinsurance_on_a_99214_usd": 27.12,
    "_example_note": "20 percent of the $135.61 moderate-complexity visit, shown as explicit arithmetic on two published figures. It applies only after the deductible is met and is $0 for the large share of beneficiaries with Medigap, Medicaid or retiree wraparound coverage."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "max_per_year": 1,
   "max_per_year_basis": "The Part B deductible is an annual amount — CMS publishes one figure per calendar year — so it is never multiplied by a number of visits.",
   "audit": {
    "id": "cms2026-part-b-deductible",
    "status": "PASS",
    "value_usd": 283,
    "basis": "out_of_pocket",
    "alternates": [],
    "facility": [],
    "frequency": [
     {
      "key": "max_per_year",
      "status": "PASS",
      "value_usd": null,
      "evidence": "The Part B deductible is an annual amount — CMS publishes one figure per calendar year — so it is never multiplied by a "
     }
    ],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": null,
    "loinc": null,
    "check": "read in the cited report",
    "evidence": "annual deductible for all Medicare Part B beneficiaries will be $283 in 2026",
    "source_url": "https://www.cms.gov/newsroom/fact-sheets/2026-medicare-parts-b-premiums-deductibles",
    "source_key": "partb",
    "extras": [
     {
      "label": "standard premium $202.90",
      "ok": true,
      "evidence": "standard monthly premium for Medicare Part B enrollees will be $202.90"
     }
    ]
   }
  },
  {
   "id": "cms2026-part-d-oop-cap",
   "label": "Medicare Part D cap on what you can pay for prescriptions in a year",
   "plain_language_synonyms": [
    "drug cap",
    "prescription cap",
    "maximum I pay for drugs"
   ],
   "value_usd": 2100,
   "out_of_pocket_usd": 2100,
   "basis": "out_of_pocket",
   "attribution": "not_applicable",
   "summable": false,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national and uniform",
   "population": "Medicare Part D enrollees",
   "coverage_statement": "The hard ceiling on a Part D enrollee's out-of-pocket prescription spending in 2026, up from $2,000 in 2025. Once reached, the enrollee pays nothing more for covered Part D drugs that year.\n\n🔴 THIS IS A CAP, NOT AN ESTIMATE OF WHAT ANYONE SPENDS. Most enrollees spend far less. It is the only published federal figure that bounds prescription out-of-pocket cost.\n\nIt would be wrong for you if you are not on Part D at all — true of most working-age people with long COVID, whose prescription cost-sharing is set by an employer plan with no comparable federal cap; if your drugs are not on your plan's formulary, since excluded drug spending does not count toward the threshold; or if you receive low-income subsidy help. The standard Part D deductible may be no more than $615 in 2026, and many plans charge less or nothing.",
   "source_title": "CMS, Final CY2026 Part D Redesign Program Instructions",
   "source_url": "https://www.cms.gov/files/document/final-cy-2026-part-d-redesign-program-instruction.pdf",
   "confidence": "VERIFIED",
   "code": null,
   "alternates": {
    "max_annual_deductible_usd": 615
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms2026-part-d-oop-cap",
    "status": "PASS",
    "value_usd": 2100,
    "basis": "out_of_pocket",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": null,
    "loinc": null,
    "check": "read in the cited report",
    "evidence": "annual OOP threshold of $2,100 for CY 2026",
    "source_url": "https://www.cms.gov/files/document/final-cy-2026-part-d-redesign-program-instruction.pdf",
    "source_key": "partd",
    "extras": [
     {
      "label": "max deductible $615",
      "ok": true,
      "evidence": "Deductible: $615"
     }
    ]
   }
  },
  {
   "id": "bls2026q2-median-weekly-earnings",
   "label": "INPUT ONLY — median weekly earnings of a full-time worker",
   "plain_language_synonyms": [
    "average pay",
    "what a week of work is worth",
    "typical wages"
   ],
   "value_usd": 1251,
   "out_of_pocket_usd": null,
   "basis": "wage",
   "attribution": "not_applicable",
   "summable": false,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026 Q2 (not seasonally adjusted; released 2026-07-21)",
   "geography": "United States, national",
   "population": "120.9 million employed full-time wage and salary workers age 16 and older. ALL self-employed people are excluded, incorporated and unincorporated.",
   "coverage_statement": "🔴 THIS IS AN INPUT, NOT A PRICE. The workdays card opens on this national median with its division shown on its face — $1,251 a week ÷ 5 — and one tap switches it to your own weekly pay, or blanks the line. It is never added to the medical total.\n\nIt is the midpoint of what employed full-time workers usually earn per week before taxes — half earn more, half less.\n\n🔴 THE LARGEST SILENT BIAS IN ANY LOST-WORK ESTIMATE: this describes a person STILL WORKING FULL TIME. It excludes part-time workers, the self-employed, the unemployed, students, retirees, people on disability, and — decisively for long COVID — anyone who cut their hours or stopped working because of the illness. The sickest people leave the denominator, so it is biased downward as a measure of illness burden, and no other series patches this.\n\nIt varies a great deal: $1,380 for men, $1,131 for women. Long COVID prevalence skews female, so an all-worker median over-prices the typical patient. BLS publishes this WEEKLY and never daily; any daily figure is arithmetic ($1,251 divided by 5 is $250.20) and must be shown as arithmetic, never cited as a government statistic.\n\nOne data note: BLS did not collect October 2025 because of the federal government shutdown, so the 2025 annual average is an eleven-month figure and 2025 Q4 was never produced at all.",
   "source_title": "U.S. Bureau of Labor Statistics, Usual Weekly Earnings of Wage and Salary Workers — Second Quarter 2026 (USDL-26-1257), series LEU0252881500",
   "source_url": "https://www.bls.gov/news.release/wkyeng.nr0.htm",
   "confidence": "VERIFIED",
   "code": null,
   "alternates": {
    "men_usd": 1380,
    "women_usd": 1131,
    "annual_average_2025_usd": 1204,
    "excess_workdays_missed_per_year_with_long_covid": 2.54,
    "_excess_days_source": "Kim et al., Long-COVID is associated with increased absenteeism from work, PLOS One 2025 — MEPS 2022, adjusted two-part model, p<0.01. Use the EXCESS 2.54 days, never the gross 8 days, because 4 of those 8 would have been missed anyway.",
    "_excess_days_url": "https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0325280"
   },
   "agency": "BLS",
   "agency_display": "BLS",
   "audit": {
    "id": "bls2026q2-median-weekly-earnings",
    "status": "PASS",
    "value_usd": 1251,
    "basis": "wage",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "BLS",
    "code": null,
    "loinc": null,
    "check": "read in the cited report",
    "evidence": "Median weekly earnings of full-time workers were $1,251 in the second quarter of 2026",
    "source_url": "https://www.bls.gov/news.release/wkyeng.nr0.htm",
    "source_key": "blswk",
    "extras": [
     {
      "label": "men $1,380",
      "ok": true,
      "evidence": "$1,380"
     },
     {
      "label": "women $1,131",
      "ok": true,
      "evidence": "$1,131"
     }
    ]
   }
  },
  {
   "id": "bls2025-caregiver-replacement-wages",
   "label": "INPUT ONLY — what an hour of paid caregiving costs to buy",
   "plain_language_synonyms": [
    "cost of a caregiver",
    "home health aide wage",
    "hiring help"
   ],
   "value_usd": 17.21,
   "out_of_pocket_usd": null,
   "basis": "wage",
   "attribution": "not_applicable",
   "summable": false,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2025 (May 2025 estimates)",
   "geography": "United States, national",
   "population": "4,305,810 employed home health and personal care aides. Excludes the self-employed and household workers hired directly by a family — which is how much paid home care actually works.",
   "coverage_statement": "🔴 AN INPUT TO A CALCULATION THIS TOOL DOES NOT MAKE FOR YOU. There is no federal dollar value for an hour of unpaid family caregiving. BLS publishes the HOURS (from its time-use survey) and the WAGE (from its occupational survey) and has never published their product; it says in its own Monthly Labor Review that putting a monetary value on unpaid household work is outside the scope of its work. So a caregiving figure can be constructed, but only as visible arithmetic over two cited federal inputs — never as a federal statistic.\n\nThe defensible range is wide and depends entirely on which task you are pricing: $17.21 an hour for custodial help, $20.32 for a nursing assistant doing clinical tasks, $46.90 for genuinely nursing-level care. That is a factor of 2.7. A different method entirely — what the caregiver GAVE UP by not working — uses the all-occupations median of $24.51, which is 42 percent away from the replacement figure and answers a different question. Showing the range is more truthful than asserting a point.\n\nThree limits travel with it. This is a WAGE, not a PRICE: a family hiring through an agency pays the agency's billed rate, materially higher because it carries overhead, supervision, insurance and margin, and BLS does not publish that rate. State variation is large. And the hours themselves come from a survey that counts primary activities only, so supervisory, on-call and simply-being-available care is largely invisible and the hours run low.\n\n🔴 A CATEGORY ERROR TO AVOID: the widely quoted BLS eldercare figure of 3.9 hours a day requires the person receiving care to be 65 or older with an AGING-RELATED condition. Long COVID is predominantly a working-age illness, so applying eldercare hours to a 38-year-old is not an approximation, it is the wrong series. The right one is 'caring for and helping household adults': 0.89 hours a day among people who did it, 5.9 percent doing it on a given day.",
   "source_title": "U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025 National Estimates; and American Time Use Survey, Table A-1, 2025 annual averages",
   "source_url": "https://www.bls.gov/oes/special-requests/oesm25nat.zip",
   "confidence": "VERIFIED",
   "code": null,
   "alternates": {
    "home_health_aide_median_hourly_usd": 17.21,
    "nursing_assistant_median_hourly_usd": 20.32,
    "registered_nurse_median_hourly_usd": 46.9,
    "all_occupations_median_hourly_usd": 24.51,
    "atus_household_adult_care_hours_per_day_among_doers": 0.89,
    "atus_share_doing_on_a_given_day_pct": 5.9,
    "atus_url": "https://www.bls.gov/tus/tables/a1-2025.pdf"
   },
   "agency": "BLS",
   "agency_display": "BLS",
   "audit": {
    "id": "bls2025-caregiver-replacement-wages",
    "status": "PASS",
    "value_usd": 17.21,
    "basis": "wage",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "BLS",
    "code": null,
    "loinc": null,
    "check": "$17.21 median hourly, Home Health and Personal Care Aides (31-1120)",
    "evidence": "plus 31-1131 $20.32, 29-1141 $46.90, 00-0000 $24.51, employment 4,305,810 — all read in the OEWS file",
    "source_url": "https://www.bls.gov/oes/special-requests/oesm25nat.zip",
    "source_key": "oews",
    "extras": []
   }
  },
  {
   "id": "cms-99202",
   "label": "First visit with a new doctor, straightforward problem",
   "plain_language_synonyms": [
    "new patient visit short",
    "first visit new doctor simple",
    "quick new patient appointment"
   ],
   "value_usd": 75.15,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A first appointment with a doctor who has never seen you before, for a straightforward problem. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 2.25 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.93 work + 1.25 non-facility practice expense + 0.07 malpractice RVUs, all four figures read in the CMS file on the line for CPT 99202 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician's fee in a freestanding office. If the visit happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 99202",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "facility_setting_physician_payment_usd": 41.08,
    "facility_setting_total_rvu": 1.23,
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 1.23 facility total RVUs x $33.4009 = $41.08. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top.",
    "facility_setting_component": "FACILITY TOTAL on the unmodified line"
   },
   "audit": {
    "id": "cms-99202",
    "status": "PASS",
    "value_usd": 75.15,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 41.08,
      "evidence": "1.23 facility total RVUs on the unmodified line for 99202 x $33.4009 = $41.08"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 99202",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "2.25 total non-facility RVUs x $33.4009 = $75.15",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-99211",
   "label": "Brief nurse visit with a doctor you already see",
   "plain_language_synonyms": [
    "nurse visit",
    "quick check in",
    "blood pressure check",
    "short follow up"
   ],
   "value_usd": 24.38,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A very brief follow-up at a practice that already knows you, often handled by a nurse rather than the physician. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.73 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.18 work + 0.54 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 99211 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician's fee in a freestanding office. If the visit happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 99211",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "facility_setting_physician_payment_usd": 7.68,
    "facility_setting_total_rvu": 0.23,
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 0.23 facility total RVUs x $33.4009 = $7.68. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top.",
    "facility_setting_component": "FACILITY TOTAL on the unmodified line"
   },
   "audit": {
    "id": "cms-99211",
    "status": "PASS",
    "value_usd": 24.38,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 7.68,
      "evidence": "0.23 facility total RVUs on the unmodified line for 99211 x $33.4009 = $7.68"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 99211",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.73 total non-facility RVUs x $33.4009 = $24.38",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-ecg",
   "label": "Heart tracing (ECG), including the doctor reading it",
   "plain_language_synonyms": [
    "ECG",
    "EKG",
    "heart tracing",
    "heart test with stickers",
    "electrocardiogram"
   ],
   "value_usd": 15.36,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The quick heart tracing done with stickers on your chest, including the physician's reading of it. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.46 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.17 work + 0.27 non-facility practice expense + 0.02 malpractice RVUs, all four figures read in the CMS file on the line for CPT 93000 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the COMPLETE service — the equipment and staff time plus the physician's interpretation. If the scan or study was done at a hospital rather than a freestanding office, the hospital bills its own facility fee on top of the physician's reading, and that second bill is not in this figure. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 93000",
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-test-ecg",
    "status": "PASS",
    "value_usd": 15.36,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 93000",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.46 total non-facility RVUs x $33.4009 = $15.36",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-stress-test",
   "label": "Treadmill stress test, complete",
   "plain_language_synonyms": [
    "stress test",
    "treadmill test",
    "exercise heart test",
    "cardiac stress test"
   ],
   "value_usd": 73.48,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The treadmill test where your heart is monitored while you walk, including supervision, tracing and interpretation. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 2.20 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.73 work + 1.43 non-facility practice expense + 0.04 malpractice RVUs, all four figures read in the CMS file on the line for CPT 93015 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the COMPLETE service — the equipment and staff time plus the physician's interpretation. If the scan or study was done at a hospital rather than a freestanding office, the hospital bills its own facility fee on top of the physician's reading, and that second bill is not in this figure. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 93015",
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-test-stress-test",
    "status": "PASS",
    "value_usd": 73.48,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 93015",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "2.20 total non-facility RVUs x $33.4009 = $73.48",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-event-monitor",
   "label": "Wearable heart event monitor, 30 days, complete",
   "plain_language_synonyms": [
    "event monitor",
    "heart monitor",
    "30 day heart monitor",
    "cardiac event recorder",
    "wearable heart monitor"
   ],
   "value_usd": 169.68,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A heart monitor you wear for up to thirty days that records episodes when your heart does something unusual — the complete service including the hookup, the recording, the scanning and the physician's report. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 5.08 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.51 work + 4.53 non-facility practice expense + 0.04 malpractice RVUs, all four figures read in the CMS file on the line for CPT 93268 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the COMPLETE service — the equipment and staff time plus the physician's interpretation. If the scan or study was done at a hospital rather than a freestanding office, the hospital bills its own facility fee on top of the physician's reading, and that second bill is not in this figure. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 93268",
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-test-event-monitor",
    "status": "PASS",
    "value_usd": 169.68,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 93268",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "5.08 total non-facility RVUs x $33.4009 = $169.68",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-sleep-study",
   "label": "Overnight sleep study in a sleep lab, complete",
   "plain_language_synonyms": [
    "sleep study",
    "overnight sleep test",
    "sleep lab",
    "polysomnogram",
    "sleep test"
   ],
   "value_usd": 673.7,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The overnight study in a sleep laboratory with a technologist present, measuring breathing, oxygen and brain activity while you sleep. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 20.17 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 2.44 work + 17.47 non-facility practice expense + 0.26 malpractice RVUs, all four figures read in the CMS file on the line for CPT 95810 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the COMPLETE service — the equipment and staff time plus the physician's interpretation. If the scan or study was done at a hospital rather than a freestanding office, the hospital bills its own facility fee on top of the physician's reading, and that second bill is not in this figure. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 95810",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "facility_setting_physician_payment_usd": 119.58,
    "facility_setting_total_rvu": 3.58,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 3.58 facility total RVUs on the modifier 26 line x $33.4009 = $119.58 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-test-sleep-study",
    "status": "PASS",
    "value_usd": 673.7,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 119.58,
      "evidence": "3.58 facility total RVUs on the modifier 26 line for 95810 x $33.4009 = $119.58"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 95810",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "20.17 total non-facility RVUs x $33.4009 = $673.70",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-eeg",
   "label": "Brain wave test (EEG), awake and asleep, complete",
   "plain_language_synonyms": [
    "EEG",
    "brain wave test",
    "brain activity test",
    "electroencephalogram",
    "brain scan with wires"
   ],
   "value_usd": 482.31,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The test with electrodes on your scalp that records your brain's electrical activity both awake and asleep. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 14.44 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.05 work + 13.28 non-facility practice expense + 0.11 malpractice RVUs, all four figures read in the CMS file on the line for CPT 95819 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the COMPLETE service — the equipment and staff time plus the physician's interpretation. If the scan or study was done at a hospital rather than a freestanding office, the hospital bills its own facility fee on top of the physician's reading, and that second bill is not in this figure. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 95819",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "facility_setting_physician_payment_usd": 56.78,
    "facility_setting_total_rvu": 1.7,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.70 facility total RVUs on the modifier 26 line x $33.4009 = $56.78 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-test-eeg",
    "status": "PASS",
    "value_usd": 482.31,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 56.78,
      "evidence": "1.70 facility total RVUs on the modifier 26 line for 95819 x $33.4009 = $56.78"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 95819",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "14.44 total non-facility RVUs x $33.4009 = $482.31",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-emg",
   "label": "Nerve and muscle test (EMG), one limb, complete",
   "plain_language_synonyms": [
    "EMG",
    "nerve test",
    "muscle test",
    "nerve conduction",
    "needle test in my muscles"
   ],
   "value_usd": 99.87,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The needle-and-electrode test of the nerves and muscles in one arm or leg, done as a complete study. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 2.99 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.84 work + 2.12 non-facility practice expense + 0.03 malpractice RVUs, all four figures read in the CMS file on the line for CPT 95886 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the COMPLETE service — the equipment and staff time plus the physician's interpretation. If the scan or study was done at a hospital rather than a freestanding office, the hospital bills its own facility fee on top of the physician's reading, and that second bill is not in this figure. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 95886",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "facility_setting_physician_payment_usd": 45.43,
    "facility_setting_total_rvu": 1.36,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.36 facility total RVUs on the modifier 26 line x $33.4009 = $45.43 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-test-emg",
    "status": "PASS",
    "value_usd": 99.87,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 45.43,
      "evidence": "1.36 facility total RVUs on the modifier 26 line for 95886 x $33.4009 = $45.43"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 95886",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "2.99 total non-facility RVUs x $33.4009 = $99.87",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-ct-head-nc",
   "label": "CT scan of the head without contrast, complete",
   "plain_language_synonyms": [
    "head CT",
    "CT of my head",
    "brain CT",
    "cat scan of my head",
    "head scan"
   ],
   "value_usd": 106.55,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A CT scan of the head or brain without dye, counting both the scan itself and the radiologist's reading. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.19 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.83 work + 2.30 non-facility practice expense + 0.06 malpractice RVUs, all four figures read in the CMS file on the line for CPT 70450 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the COMPLETE service — the equipment and staff time plus the physician's interpretation. If the scan or study was done at a hospital rather than a freestanding office, the hospital bills its own facility fee on top of the physician's reading, and that second bill is not in this figure. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 70450",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "facility_setting_physician_payment_usd": 39.41,
    "facility_setting_total_rvu": 1.18,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.18 facility total RVUs on the modifier 26 line x $33.4009 = $39.41 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-ct-head-nc",
    "status": "PASS",
    "value_usd": 106.55,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 39.41,
      "evidence": "1.18 facility total RVUs on the modifier 26 line for 70450 x $33.4009 = $39.41"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 70450",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.19 total non-facility RVUs x $33.4009 = $106.55",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-mri-lumbar-nc",
   "label": "MRI of the lower back without contrast, complete",
   "plain_language_synonyms": [
    "back MRI",
    "lumbar MRI",
    "MRI of my lower back",
    "spine MRI",
    "low back scan"
   ],
   "value_usd": 191.72,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An MRI of the lower spine without dye, counting both the scan and the radiologist's reading. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 5.74 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.44 work + 4.20 non-facility practice expense + 0.10 malpractice RVUs, all four figures read in the CMS file on the line for CPT 72148 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the COMPLETE service — the equipment and staff time plus the physician's interpretation. If the scan or study was done at a hospital rather than a freestanding office, the hospital bills its own facility fee on top of the physician's reading, and that second bill is not in this figure. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 72148",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "facility_setting_physician_payment_usd": 68.47,
    "facility_setting_total_rvu": 2.05,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 2.05 facility total RVUs on the modifier 26 line x $33.4009 = $68.47 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-mri-lumbar-nc",
    "status": "PASS",
    "value_usd": 191.72,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 68.47,
      "evidence": "2.05 facility total RVUs on the modifier 26 line for 72148 x $33.4009 = $68.47"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 72148",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "5.74 total non-facility RVUs x $33.4009 = $191.72",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-mri-joint-nc",
   "label": "MRI of a knee or other lower-limb joint without contrast, complete",
   "plain_language_synonyms": [
    "knee MRI",
    "MRI of my knee",
    "joint MRI",
    "ankle MRI",
    "hip MRI"
   ],
   "value_usd": 204.41,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An MRI of a joint in the leg — knee, ankle or hip — without dye, counting both the scan and the reading. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 6.12 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.32 work + 4.71 non-facility practice expense + 0.09 malpractice RVUs, all four figures read in the CMS file on the line for CPT 73721 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the COMPLETE service — the equipment and staff time plus the physician's interpretation. If the scan or study was done at a hospital rather than a freestanding office, the hospital bills its own facility fee on top of the physician's reading, and that second bill is not in this figure. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 73721",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "facility_setting_physician_payment_usd": 62.79,
    "facility_setting_total_rvu": 1.88,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.88 facility total RVUs on the modifier 26 line x $33.4009 = $62.79 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-mri-joint-nc",
    "status": "PASS",
    "value_usd": 204.41,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 62.79,
      "evidence": "1.88 facility total RVUs on the modifier 26 line for 73721 x $33.4009 = $62.79"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 73721",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "6.12 total non-facility RVUs x $33.4009 = $204.41",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-us-abdomen",
   "label": "Ultrasound of the abdomen, complete, including the reading",
   "plain_language_synonyms": [
    "belly ultrasound",
    "abdominal ultrasound",
    "stomach ultrasound",
    "ultrasound of my belly"
   ],
   "value_usd": 114.23,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A complete ultrasound of the abdomen, counting both the scan and the radiologist's reading. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.42 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.79 work + 2.57 non-facility practice expense + 0.06 malpractice RVUs, all four figures read in the CMS file on the line for CPT 76700 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the COMPLETE service — the equipment and staff time plus the physician's interpretation. If the scan or study was done at a hospital rather than a freestanding office, the hospital bills its own facility fee on top of the physician's reading, and that second bill is not in this figure. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 76700",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "facility_setting_physician_payment_usd": 37.41,
    "facility_setting_total_rvu": 1.12,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.12 facility total RVUs on the modifier 26 line x $33.4009 = $37.41 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-us-abdomen",
    "status": "PASS",
    "value_usd": 114.23,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 37.41,
      "evidence": "1.12 facility total RVUs on the modifier 26 line for 76700 x $33.4009 = $37.41"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 76700",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.42 total non-facility RVUs x $33.4009 = $114.23",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-us-pelvic",
   "label": "Pelvic ultrasound, complete, including the reading",
   "plain_language_synonyms": [
    "pelvic ultrasound",
    "ultrasound of my pelvis",
    "transabdominal pelvic ultrasound"
   ],
   "value_usd": 105.21,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A complete pelvic ultrasound, counting both the scan and the radiologist's reading. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.15 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.67 work + 2.43 non-facility practice expense + 0.05 malpractice RVUs, all four figures read in the CMS file on the line for CPT 76856 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the COMPLETE service — the equipment and staff time plus the physician's interpretation. If the scan or study was done at a hospital rather than a freestanding office, the hospital bills its own facility fee on top of the physician's reading, and that second bill is not in this figure. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 76856",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "facility_setting_physician_payment_usd": 32.4,
    "facility_setting_total_rvu": 0.97,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 0.97 facility total RVUs on the modifier 26 line x $33.4009 = $32.40 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-us-pelvic",
    "status": "PASS",
    "value_usd": 105.21,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 32.4,
      "evidence": "0.97 facility total RVUs on the modifier 26 line for 76856 x $33.4009 = $32.40"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 76856",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.15 total non-facility RVUs x $33.4009 = $105.21",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-carotid-duplex",
   "label": "Ultrasound of the neck arteries (carotid duplex), complete",
   "plain_language_synonyms": [
    "carotid ultrasound",
    "neck artery ultrasound",
    "carotid duplex",
    "neck scan for stroke risk"
   ],
   "value_usd": 189.05,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The ultrasound of the arteries in your neck that checks blood flow to the brain, counting both the scan and the reading. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 5.66 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.78 work + 4.78 non-facility practice expense + 0.10 malpractice RVUs, all four figures read in the CMS file on the line for CPT 93880 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the COMPLETE service — the equipment and staff time plus the physician's interpretation. If the scan or study was done at a hospital rather than a freestanding office, the hospital bills its own facility fee on top of the physician's reading, and that second bill is not in this figure. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 93880",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "facility_setting_physician_payment_usd": 37.41,
    "facility_setting_total_rvu": 1.12,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.12 facility total RVUs on the modifier 26 line x $33.4009 = $37.41 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-carotid-duplex",
    "status": "PASS",
    "value_usd": 189.05,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 37.41,
      "evidence": "1.12 facility total RVUs on the modifier 26 line for 93880 x $33.4009 = $37.41"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 93880",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "5.66 total non-facility RVUs x $33.4009 = $189.05",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-ct-abd-pelvis-c",
   "label": "CT of the abdomen and pelvis with contrast, complete",
   "plain_language_synonyms": [
    "CT of my belly",
    "abdominal CT",
    "CT abdomen pelvis",
    "cat scan of my stomach",
    "belly scan with dye"
   ],
   "value_usd": 300.27,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A CT scan of the abdomen and pelvis with dye, counting both the scan and the radiologist's reading. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 8.99 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.77 work + 7.09 non-facility practice expense + 0.13 malpractice RVUs, all four figures read in the CMS file on the line for CPT 74177 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the COMPLETE service — the equipment and staff time plus the physician's interpretation. If the scan or study was done at a hospital rather than a freestanding office, the hospital bills its own facility fee on top of the physician's reading, and that second bill is not in this figure. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 74177",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "facility_setting_physician_payment_usd": 83.84,
    "facility_setting_total_rvu": 2.51,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 2.51 facility total RVUs on the modifier 26 line x $33.4009 = $83.84 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-ct-abd-pelvis-c",
    "status": "PASS",
    "value_usd": 300.27,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 83.84,
      "evidence": "2.51 facility total RVUs on the modifier 26 line for 74177 x $33.4009 = $83.84"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 74177",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "8.99 total non-facility RVUs x $33.4009 = $300.27",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-colonoscopy",
   "label": "Diagnostic colonoscopy, physician's fee",
   "plain_language_synonyms": [
    "colonoscopy",
    "scope",
    "camera in my colon",
    "bowel scope"
   ],
   "value_usd": 378.1,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A diagnostic colonoscopy — the physician's fee for the procedure itself. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 11.32 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 3.18 work + 7.73 non-facility practice expense + 0.41 malpractice RVUs, all four figures read in the CMS file on the line for CPT 45378 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the PHYSICIAN'S FEE ONLY. A procedure like this is almost always done in a hospital or a surgery center, which bills a separate facility fee that is usually the larger of the two bills, and anesthesia is billed separately again. Do not read this as the price of the day. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 45378",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "facility_setting_physician_payment_usd": 164.67,
    "facility_setting_total_rvu": 4.93,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 4.93 facility total RVUs x $33.4009 = $164.67. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-colonoscopy",
    "status": "PASS",
    "value_usd": 378.1,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 164.67,
      "evidence": "4.93 facility total RVUs on the unmodified line for 45378 x $33.4009 = $164.67"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 45378",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "11.32 total non-facility RVUs x $33.4009 = $378.10",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-egd-biopsy",
   "label": "Upper endoscopy with biopsy, physician's fee",
   "plain_language_synonyms": [
    "upper endoscopy",
    "EGD",
    "scope down my throat",
    "stomach scope",
    "endoscopy with biopsy"
   ],
   "value_usd": 418.85,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An endoscopy of the esophagus and stomach with one or more biopsies taken — the physician's fee for the procedure. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 12.54 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 2.33 work + 9.94 non-facility practice expense + 0.27 malpractice RVUs, all four figures read in the CMS file on the line for CPT 43239 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the PHYSICIAN'S FEE ONLY. A procedure like this is almost always done in a hospital or a surgery center, which bills a separate facility fee that is usually the larger of the two bills, and anesthesia is billed separately again. Do not read this as the price of the day. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 43239",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "facility_setting_physician_payment_usd": 123.58,
    "facility_setting_total_rvu": 3.7,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 3.70 facility total RVUs x $33.4009 = $123.58. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-egd-biopsy",
    "status": "PASS",
    "value_usd": 418.85,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 123.58,
      "evidence": "3.70 facility total RVUs on the unmodified line for 43239 x $33.4009 = $123.58"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 43239",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "12.54 total non-facility RVUs x $33.4009 = $418.85",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-pt-eval-low",
   "label": "Physical therapy evaluation, low complexity",
   "plain_language_synonyms": [
    "PT eval",
    "physical therapy evaluation",
    "first physical therapy visit",
    "PT assessment"
   ],
   "value_usd": 97.86,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The first physical therapy appointment, where the therapist evaluates you and builds a plan, at the lower complexity level. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 2.93 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.54 work + 1.38 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 97161 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician's fee in a freestanding office. If the visit happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 97161",
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-pt-eval-low",
    "status": "PASS",
    "value_usd": 97.86,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 97161",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "2.93 total non-facility RVUs x $33.4009 = $97.86",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-pt-exercise-15",
   "label": "Physical therapy exercise session, 15 minutes",
   "plain_language_synonyms": [
    "physical therapy session",
    "PT session",
    "therapeutic exercise",
    "physical therapy",
    "PT appointment"
   ],
   "value_usd": 29.06,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "Fifteen minutes of supervised therapeutic exercise with a physical therapist. A typical session bills several of these units, so one visit usually costs a multiple of this figure. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.87 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.45 work + 0.41 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 97110 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is ONE 15-minute unit. A real therapy visit bills two to four units, so multiply. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 97110",
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-pt-exercise-15",
    "status": "PASS",
    "value_usd": 29.06,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 97110",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.87 total non-facility RVUs x $33.4009 = $29.06",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-eye-exam-new",
   "label": "Comprehensive eye exam, new patient",
   "plain_language_synonyms": [
    "eye exam",
    "eye doctor visit",
    "vision exam",
    "comprehensive eye exam",
    "optometrist visit"
   ],
   "value_usd": 149.64,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A full eye examination for a patient the eye doctor has not seen before. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 4.48 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.82 work + 2.62 non-facility practice expense + 0.04 malpractice RVUs, all four figures read in the CMS file on the line for CPT 92004 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician's fee in a freestanding office. If the visit happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 92004",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "facility_setting_physician_payment_usd": 77.82,
    "facility_setting_total_rvu": 2.33,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 2.33 facility total RVUs x $33.4009 = $77.82. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-eye-exam-new",
    "status": "PASS",
    "value_usd": 149.64,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 77.82,
      "evidence": "2.33 facility total RVUs on the unmodified line for 92004 x $33.4009 = $77.82"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 92004",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "4.48 total non-facility RVUs x $33.4009 = $149.64",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-neurobehavioral-1h",
   "label": "Neurobehavioral status exam by a clinician, first hour",
   "plain_language_synonyms": [
    "cognitive testing",
    "memory testing",
    "brain fog testing",
    "thinking test",
    "neurobehavioral exam"
   ],
   "value_usd": 94.19,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The first hour of a clinician-administered examination of thinking, memory, attention and language — the test many people with brain fog are sent for. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 2.82 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.86 work + 0.90 non-facility practice expense + 0.06 malpractice RVUs, all four figures read in the CMS file on the line for CPT 96116 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the FIRST hour only. Longer testing bills add-on units beyond this figure. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 96116",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "facility_setting_physician_payment_usd": 72.15,
    "facility_setting_total_rvu": 2.16,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 2.16 facility total RVUs x $33.4009 = $72.15. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-test-neurobehavioral-1h",
    "status": "PASS",
    "value_usd": 94.19,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 72.15,
      "evidence": "2.16 facility total RVUs on the unmodified line for 96116 x $33.4009 = $72.15"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 96116",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "2.82 total non-facility RVUs x $33.4009 = $94.19",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-neuropsych-1h",
   "label": "Neuropsychological testing evaluation by a clinician, first hour",
   "plain_language_synonyms": [
    "neuropsych testing",
    "neuropsychological evaluation",
    "full cognitive testing",
    "brain testing"
   ],
   "value_usd": 122.25,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The first hour of a neuropsychologist's evaluation — interpreting the test results, integrating records and planning care. A full evaluation runs several hours and bills add-on units beyond this first one. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.66 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 2.56 work + 1.03 non-facility practice expense + 0.07 malpractice RVUs, all four figures read in the CMS file on the line for CPT 96132 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the FIRST hour only. Longer testing bills add-on units beyond this figure. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 96132",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "facility_setting_physician_payment_usd": 98.53,
    "facility_setting_total_rvu": 2.95,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 2.95 facility total RVUs x $33.4009 = $98.53. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-test-neuropsych-1h",
    "status": "PASS",
    "value_usd": 122.25,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 98.53,
      "evidence": "2.95 facility total RVUs on the unmodified line for 96132 x $33.4009 = $98.53"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 96132",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.66 total non-facility RVUs x $33.4009 = $122.25",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-allergy-skin-per-test",
   "label": "Allergy skin test, price per individual allergen tested",
   "plain_language_synonyms": [
    "allergy testing",
    "allergy skin test",
    "scratch test",
    "skin prick test",
    "allergy pricks"
   ],
   "value_usd": 3.67,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The scratch or prick allergy test — and this is the price for ONE allergen. A real allergy panel tests dozens at a sitting, so multiply this figure by the number of pricks to price your visit. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.11 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.01 work + 0.09 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 95004 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the price for ONE test in the series. Multiply by the number performed. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 95004",
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-test-allergy-skin-per-test",
    "status": "PASS",
    "value_usd": 3.67,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 95004",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.11 total non-facility RVUs x $33.4009 = $3.67",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-hearing",
   "label": "Comprehensive hearing test",
   "plain_language_synonyms": [
    "hearing test",
    "audiogram",
    "hearing exam",
    "audiology test"
   ],
   "value_usd": 35.74,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The full hearing test in a sound booth, covering both the pure-tone thresholds and the speech testing. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.07 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.60 work + 0.46 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 92557 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the COMPLETE service — the equipment and staff time plus the physician's interpretation. If the scan or study was done at a hospital rather than a freestanding office, the hospital bills its own facility fee on top of the physician's reading, and that second bill is not in this figure. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 92557",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "facility_setting_physician_payment_usd": 25.72,
    "facility_setting_total_rvu": 0.77,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 0.77 facility total RVUs x $33.4009 = $25.72. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-test-hearing",
    "status": "PASS",
    "value_usd": 35.74,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 25.72,
      "evidence": "0.77 facility total RVUs on the unmodified line for 92557 x $33.4009 = $25.72"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 92557",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.07 total non-facility RVUs x $33.4009 = $35.74",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-joint-injection",
   "label": "Injection or fluid draw from a large joint, without ultrasound guidance",
   "plain_language_synonyms": [
    "cortisone shot",
    "joint injection",
    "steroid shot in my knee",
    "knee injection",
    "joint aspiration"
   ],
   "value_usd": 68.81,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The steroid injection into, or fluid drawn out of, a large joint such as a knee, hip or shoulder, done without ultrasound guidance. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 2.06 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.77 work + 1.16 non-facility practice expense + 0.13 malpractice RVUs, all four figures read in the CMS file on the line for CPT 20610 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the PHYSICIAN'S FEE ONLY. A procedure like this is almost always done in a hospital or a surgery center, which bills a separate facility fee that is usually the larger of the two bills, and anesthesia is billed separately again. Do not read this as the price of the day. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 20610",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "facility_setting_physician_payment_usd": 39.75,
    "facility_setting_total_rvu": 1.19,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 1.19 facility total RVUs x $33.4009 = $39.75. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-joint-injection",
    "status": "PASS",
    "value_usd": 68.81,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 39.75,
      "evidence": "1.19 facility total RVUs on the unmodified line for 20610 x $33.4009 = $39.75"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 20610",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "2.06 total non-facility RVUs x $33.4009 = $68.81",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-lab-vitamin-d",
   "label": "Vitamin D level",
   "plain_language_synonyms": [
    "vitamin D test",
    "vit d",
    "vitamin d level",
    "25-hydroxy vitamin D"
   ],
   "value_usd": 29.6,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $29.60 is the payment amount printed on the row for CPT 82306 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 82306",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "62292-8",
   "loinc_long_common_name": "25-Hydroxyvitamin D3+25-Hydroxyvitamin D2 [Mass/volume] in Serum or Plasma",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-vitamin-d",
    "status": "PASS",
    "value_usd": 29.6,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 82306",
    "loinc": "62292-8",
    "check": "CLFS lookup",
    "evidence": "CPT 82306 pays $29.60 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-b12",
   "label": "Vitamin B12 level",
   "plain_language_synonyms": [
    "b12 test",
    "vitamin b12",
    "b-12 level"
   ],
   "value_usd": 15.08,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $15.08 is the payment amount printed on the row for CPT 82607 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 82607",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "2132-9",
   "loinc_long_common_name": "Cobalamin (Vitamin B12) [Mass/volume] in Serum or Plasma",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-b12",
    "status": "PASS",
    "value_usd": 15.08,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 82607",
    "loinc": "2132-9",
    "check": "CLFS lookup",
    "evidence": "CPT 82607 pays $15.08 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-a1c",
   "label": "Hemoglobin A1c (three-month blood sugar)",
   "plain_language_synonyms": [
    "a1c",
    "hba1c",
    "diabetes test",
    "three month sugar test"
   ],
   "value_usd": 9.71,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $9.71 is the payment amount printed on the row for CPT 83036 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 83036",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "4548-4",
   "loinc_long_common_name": "Hemoglobin A1c/Hemoglobin.total in Blood",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-a1c",
    "status": "PASS",
    "value_usd": 9.71,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 83036",
    "loinc": "4548-4",
    "check": "CLFS lookup",
    "evidence": "CPT 83036 pays $9.71 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-lipid-panel",
   "label": "Cholesterol panel",
   "plain_language_synonyms": [
    "cholesterol panel",
    "lipid panel",
    "cholesterol test",
    "lipids"
   ],
   "value_usd": 13.39,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $13.39 is the payment amount printed on the row for CPT 80061 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 80061",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "24331-1",
   "loinc_long_common_name": "Lipid 1996 panel - Serum or Plasma",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-lipid-panel",
    "status": "PASS",
    "value_usd": 13.39,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 80061",
    "loinc": "24331-1",
    "check": "CLFS lookup",
    "evidence": "CPT 80061 pays $13.39 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-free-t4",
   "label": "Free T4 thyroid hormone",
   "plain_language_synonyms": [
    "free t4",
    "thyroid hormone test",
    "t4 level"
   ],
   "value_usd": 9.02,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $9.02 is the payment amount printed on the row for CPT 84439 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 84439",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "3024-7",
   "loinc_long_common_name": "Thyroxine (T4) free [Mass/volume] in Serum or Plasma",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-free-t4",
    "status": "PASS",
    "value_usd": 9.02,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 84439",
    "loinc": "3024-7",
    "check": "CLFS lookup",
    "evidence": "CPT 84439 pays $9.02 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-glucose",
   "label": "Blood sugar (glucose)",
   "plain_language_synonyms": [
    "sugar test",
    "glucose test",
    "blood sugar test"
   ],
   "value_usd": 3.93,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $3.93 is the payment amount printed on the row for CPT 82947 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 82947",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "2345-7",
   "loinc_long_common_name": "Glucose [Mass/volume] in Serum or Plasma",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-glucose",
    "status": "PASS",
    "value_usd": 3.93,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 82947",
    "loinc": "2345-7",
    "check": "CLFS lookup",
    "evidence": "CPT 82947 pays $3.93 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-urinalysis",
   "label": "Urine test with microscope",
   "plain_language_synonyms": [
    "urine test",
    "urinalysis",
    "pee test",
    "urine sample"
   ],
   "value_usd": 3.17,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $3.17 is the payment amount printed on the row for CPT 81001 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 81001",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "24356-8",
   "loinc_long_common_name": "Urinalysis complete panel - Urine",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-urinalysis",
    "status": "PASS",
    "value_usd": 3.17,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 81001",
    "loinc": "24356-8",
    "check": "CLFS lookup",
    "evidence": "CPT 81001 pays $3.17 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-urine-culture",
   "label": "Urine culture",
   "plain_language_synonyms": [
    "urine culture",
    "UTI test",
    "bladder infection test"
   ],
   "value_usd": 8.07,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $8.07 is the payment amount printed on the row for CPT 87086 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 87086",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "630-4",
   "loinc_long_common_name": "Bacteria identified in Urine by Culture",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-urine-culture",
    "status": "PASS",
    "value_usd": 8.07,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 87086",
    "loinc": "630-4",
    "check": "CLFS lookup",
    "evidence": "CPT 87086 pays $8.07 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-covid-pcr",
   "label": "COVID-19 PCR test",
   "plain_language_synonyms": [
    "covid test",
    "covid pcr",
    "sars-cov-2 test",
    "pcr test"
   ],
   "value_usd": 51.31,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $51.31 is the payment amount printed on the row for CPT 87635 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 87635",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "94500-6",
   "loinc_long_common_name": "SARS-CoV-2 (COVID-19) RNA [Presence] in Respiratory system specimen by NAA with probe detection",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-covid-pcr",
    "status": "PASS",
    "value_usd": 51.31,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 87635",
    "loinc": "94500-6",
    "check": "CLFS lookup",
    "evidence": "CPT 87635 pays $51.31 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-magnesium",
   "label": "Magnesium level",
   "plain_language_synonyms": [
    "magnesium test",
    "mag level"
   ],
   "value_usd": 6.7,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $6.70 is the payment amount printed on the row for CPT 83735 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 83735",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "19123-9",
   "loinc_long_common_name": "Magnesium [Mass/volume] in Serum or Plasma",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-magnesium",
    "status": "PASS",
    "value_usd": 6.7,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 83735",
    "loinc": "19123-9",
    "check": "CLFS lookup",
    "evidence": "CPT 83735 pays $6.70 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-ck",
   "label": "Creatine kinase (muscle enzyme)",
   "plain_language_synonyms": [
    "CK test",
    "muscle enzyme test",
    "creatine kinase",
    "CPK"
   ],
   "value_usd": 6.51,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $6.51 is the payment amount printed on the row for CPT 82550 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 82550",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "2157-6",
   "loinc_long_common_name": "Creatine kinase [Enzymatic activity/volume] in Serum or Plasma",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-ck",
    "status": "PASS",
    "value_usd": 6.51,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 82550",
    "loinc": "2157-6",
    "check": "CLFS lookup",
    "evidence": "CPT 82550 pays $6.51 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-bnp",
   "label": "BNP heart strain test",
   "plain_language_synonyms": [
    "BNP",
    "heart failure blood test",
    "natriuretic peptide"
   ],
   "value_usd": 39.26,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $39.26 is the payment amount printed on the row for CPT 83880 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 83880",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "30934-4",
   "loinc_long_common_name": "Natriuretic peptide B [Mass/volume] in Serum or Plasma",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-bnp",
    "status": "PASS",
    "value_usd": 39.26,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 83880",
    "loinc": "30934-4",
    "check": "CLFS lookup",
    "evidence": "CPT 83880 pays $39.26 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-troponin",
   "label": "Troponin (heart injury test)",
   "plain_language_synonyms": [
    "troponin",
    "heart attack blood test",
    "cardiac enzyme"
   ],
   "value_usd": 12.47,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $12.47 is the payment amount printed on the row for CPT 84484 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 84484",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-lab-troponin",
    "status": "PASS",
    "value_usd": 12.47,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 84484",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 84484 pays $12.47 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-pt-inr",
   "label": "Prothrombin time / INR (clotting)",
   "plain_language_synonyms": [
    "INR",
    "prothrombin time",
    "clotting test",
    "PT test"
   ],
   "value_usd": 4.29,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $4.29 is the payment amount printed on the row for CPT 85610 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 85610",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "5902-2",
   "loinc_long_common_name": "Prothrombin time (PT)",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-pt-inr",
    "status": "PASS",
    "value_usd": 4.29,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 85610",
    "loinc": "5902-2",
    "check": "CLFS lookup",
    "evidence": "CPT 85610 pays $4.29 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-ptt",
   "label": "Partial thromboplastin time (clotting)",
   "plain_language_synonyms": [
    "PTT",
    "aPTT",
    "clotting time test"
   ],
   "value_usd": 6.01,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $6.01 is the payment amount printed on the row for CPT 85730 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 85730",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "14979-9",
   "loinc_long_common_name": "aPTT in Platelet poor plasma by Coagulation assay",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-ptt",
    "status": "PASS",
    "value_usd": 6.01,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 85730",
    "loinc": "14979-9",
    "check": "CLFS lookup",
    "evidence": "CPT 85730 pays $6.01 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-ena",
   "label": "ENA autoantibody panel",
   "plain_language_synonyms": [
    "ENA panel",
    "autoimmune antibody test",
    "extractable nuclear antigen"
   ],
   "value_usd": 17.93,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $17.93 is the payment amount printed on the row for CPT 86235 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 86235",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "90228-8",
   "loinc_long_common_name": "Extractable nuclear antigen Ab.IgG panel - Serum",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-ena",
    "status": "PASS",
    "value_usd": 17.93,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 86235",
    "loinc": "90228-8",
    "check": "CLFS lookup",
    "evidence": "CPT 86235 pays $17.93 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-dsdna",
   "label": "Double-stranded DNA antibody (lupus test)",
   "plain_language_synonyms": [
    "dsDNA",
    "lupus blood test",
    "anti-dna antibody"
   ],
   "value_usd": 13.74,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $13.74 is the payment amount printed on the row for CPT 86225 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 86225",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "5130-0",
   "loinc_long_common_name": "DNA double strand Ab [Units/volume] in Serum",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-dsdna",
    "status": "PASS",
    "value_usd": 13.74,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 86225",
    "loinc": "5130-0",
    "check": "CLFS lookup",
    "evidence": "CPT 86225 pays $13.74 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-ige-per-allergen",
   "label": "Allergy blood test, price per allergen tested",
   "plain_language_synonyms": [
    "allergy blood test",
    "IgE test",
    "RAST test",
    "food allergy blood test"
   ],
   "value_usd": 5.22,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $5.22 is the payment amount printed on the row for CPT 86003 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 86003",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "audit": {
    "id": "cms-lab-ige-per-allergen",
    "status": "PASS",
    "value_usd": 5.22,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 86003",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 86003 pays $5.22 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-free-testosterone",
   "label": "Free testosterone",
   "plain_language_synonyms": [
    "free testosterone",
    "testosterone test"
   ],
   "value_usd": 25.47,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $25.47 is the payment amount printed on the row for CPT 84402 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 84402",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "2991-8",
   "loinc_long_common_name": "Testosterone Free [Mass/volume] in Serum or Plasma",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-free-testosterone",
    "status": "PASS",
    "value_usd": 25.47,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 84402",
    "loinc": "2991-8",
    "check": "CLFS lookup",
    "evidence": "CPT 84402 pays $25.47 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-fsh",
   "label": "FSH hormone level",
   "plain_language_synonyms": [
    "FSH",
    "follicle stimulating hormone",
    "fertility hormone test"
   ],
   "value_usd": 18.58,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $18.58 is the payment amount printed on the row for CPT 83001 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 83001",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "15067-2",
   "loinc_long_common_name": "Follitropin [Units/volume] in Serum or Plasma",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-fsh",
    "status": "PASS",
    "value_usd": 18.58,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 83001",
    "loinc": "15067-2",
    "check": "CLFS lookup",
    "evidence": "CPT 83001 pays $18.58 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-estradiol",
   "label": "Estradiol (estrogen) level",
   "plain_language_synonyms": [
    "estradiol",
    "estrogen test",
    "estrogen level"
   ],
   "value_usd": 27.94,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $27.94 is the payment amount printed on the row for CPT 82670 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 82670",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "2243-4",
   "loinc_long_common_name": "Estradiol (E2) [Mass/volume] in Serum or Plasma",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-estradiol",
    "status": "PASS",
    "value_usd": 27.94,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 82670",
    "loinc": "2243-4",
    "check": "CLFS lookup",
    "evidence": "CPT 82670 pays $27.94 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-prolactin",
   "label": "Prolactin level",
   "plain_language_synonyms": [
    "prolactin",
    "prolactin test"
   ],
   "value_usd": 19.38,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $19.38 is the payment amount printed on the row for CPT 84146 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 84146",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "2842-3",
   "loinc_long_common_name": "Prolactin [Mass/volume] in Serum or Plasma",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-prolactin",
    "status": "PASS",
    "value_usd": 19.38,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 84146",
    "loinc": "2842-3",
    "check": "CLFS lookup",
    "evidence": "CPT 84146 pays $19.38 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-iron-binding",
   "label": "Iron binding capacity",
   "plain_language_synonyms": [
    "iron binding",
    "TIBC",
    "iron studies"
   ],
   "value_usd": 8.74,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $8.74 is the payment amount printed on the row for CPT 83550 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 83550",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "2500-7",
   "loinc_long_common_name": "Iron binding capacity [Mass/volume] in Serum or Plasma",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-iron-binding",
    "status": "PASS",
    "value_usd": 8.74,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 83550",
    "loinc": "2500-7",
    "check": "CLFS lookup",
    "evidence": "CPT 83550 pays $8.74 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-folate",
   "label": "Folate (folic acid) level",
   "plain_language_synonyms": [
    "folate test",
    "folic acid level"
   ],
   "value_usd": 14.7,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $14.70 is the payment amount printed on the row for CPT 82746 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 82746",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "2284-8",
   "loinc_long_common_name": "Folate [Mass/volume] in Serum or Plasma",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-folate",
    "status": "PASS",
    "value_usd": 14.7,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 82746",
    "loinc": "2284-8",
    "check": "CLFS lookup",
    "evidence": "CPT 82746 pays $14.70 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-syphilis",
   "label": "Syphilis antibody test",
   "plain_language_synonyms": [
    "syphilis test",
    "treponema test"
   ],
   "value_usd": 13.24,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $13.24 is the payment amount printed on the row for CPT 86780 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 86780",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "24110-9",
   "loinc_long_common_name": "Treponema pallidum Ab [Presence] in Serum by Immunoassay",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-syphilis",
    "status": "PASS",
    "value_usd": 13.24,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 86780",
    "loinc": "24110-9",
    "check": "CLFS lookup",
    "evidence": "CPT 86780 pays $13.24 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-hep-b-surface-ag",
   "label": "Hepatitis B surface antigen",
   "plain_language_synonyms": [
    "hepatitis b test",
    "hep b test",
    "HBsAg"
   ],
   "value_usd": 10.33,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $10.33 is the payment amount printed on the row for CPT 87340 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 87340",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "5196-1",
   "loinc_long_common_name": "Hepatitis B virus surface Ag [Presence] in Serum or Plasma by Immunoassay",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-hep-b-surface-ag",
    "status": "PASS",
    "value_usd": 10.33,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 87340",
    "loinc": "5196-1",
    "check": "CLFS lookup",
    "evidence": "CPT 87340 pays $10.33 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-hep-c-ab",
   "label": "Hepatitis C antibody",
   "plain_language_synonyms": [
    "hepatitis c test",
    "hep c test",
    "HCV antibody"
   ],
   "value_usd": 14.27,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $14.27 is the payment amount printed on the row for CPT 86803 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 86803",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "16128-1",
   "loinc_long_common_name": "Hepatitis C virus Ab [Presence] in Serum",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-hep-c-ab",
    "status": "PASS",
    "value_usd": 14.27,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 86803",
    "loinc": "16128-1",
    "check": "CLFS lookup",
    "evidence": "CPT 86803 pays $14.27 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-hiv",
   "label": "HIV antigen/antibody test",
   "plain_language_synonyms": [
    "HIV test",
    "hiv screening",
    "4th generation hiv test"
   ],
   "value_usd": 24.08,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The published Medicare rate for this laboratory test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $24.08 is the payment amount printed on the row for CPT 87389 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — clinical laboratory tests carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory's charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "confidence": "VERIFIED",
   "code": "CPT 87389",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Clinical lab tests carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "agency": "CMS",
   "agency_display": "CMS",
   "loinc": "56888-1",
   "loinc_long_common_name": "HIV 1+2 Ab+HIV1 p24 Ag [Presence] in Serum or Plasma by Immunoassay",
   "loinc_source": "NLM Clinical Table Search Service, LOINC table (https://clinicaltables.nlm.nih.gov/apidoc/loinc_items/v3/doc.html)",
   "audit": {
    "id": "cms-lab-hiv",
    "status": "PASS",
    "value_usd": 24.08,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 87389",
    "loinc": "56888-1",
    "check": "CLFS lookup",
    "evidence": "CPT 87389 pays $24.08 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "gsa2026-pov-mileage-rate",
   "label": "INPUT ONLY — the federal mileage rate for driving your own car",
   "plain_language_synonyms": [
    "mileage",
    "driving to appointments",
    "gas money",
    "miles driven",
    "travel to the doctor"
   ],
   "value_usd": 0.76,
   "out_of_pocket_usd": null,
   "basis": "rate",
   "attribution": "not_applicable",
   "summable": false,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "effective July 1, 2026",
   "geography": "United States, one national rate",
   "population": "Federal employees travelling on official business. NOT patients.",
   "coverage_statement": "🔴 THIS IS NOT A MEDICAL PRICE AND NOBODY WILL PAY IT TO YOU. It is the rate the federal government reimburses its OWN employees, per mile, for driving a personal car on official travel — $0.76 a mile, effective July 1, 2026. It is in this table for one reason: the driving a long diagnostic search costs is real, and the only published federal figure that puts a dollar on a mile is this one. If you count your miles with it you are borrowing the government's own number for its own travel, which is a defensible thing to do and a different thing from a bill.\n\nIt cannot be added to any medical line here: those are prices for care, this is a reimbursement rate for transport. It sits in its own stack, always.\n\nWho it describes: federal travellers. Who it does NOT describe: patients, whose actual cost per mile depends on the car, the fuel price and the year, and for whom no federal agency publishes a figure at all. The IRS publishes a separate and lower MEDICAL mileage deduction rate; it is a tax rule, not a price, and it is not this.",
   "source_title": "U.S. General Services Administration, POV mileage reimbursement rates, automobile rate effective July 1, 2026",
   "source_url": "https://www.gsa.gov/travel/plan-a-trip/transportation-airfare-rates-pov-rates/pov-mileage-reimbursement",
   "confidence": "VERIFIED",
   "code": null,
   "agency": "GSA",
   "agency_display": "GSA",
   "alternates": {
    "_quote_read_on_the_page": "no government-owned automobile was authorized or available $0.76 per mile"
   },
   "audit": {
    "id": "gsa2026-pov-mileage-rate",
    "status": "PASS",
    "value_usd": 0.76,
    "basis": "rate",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "GSA",
    "code": null,
    "loinc": null,
    "check": "read in the cited report",
    "evidence": "no government-owned automobile was authorized or available $0.76 per mile",
    "source_url": "https://www.gsa.gov/travel/plan-a-trip/transportation-airfare-rates-pov-rates/pov-mileage-reimbursement",
    "source_key": "gsa",
    "extras": []
   }
  },
  {
   "id": "cms-96127",
   "label": "Short scored questionnaire for anxiety, depression or attention",
   "plain_language_synonyms": [
    "filled out a depression questionnaire",
    "anxiety questionnaire",
    "PHQ-9",
    "GAD-7",
    "mental health screening form",
    "screening questionnaire at the visit",
    "depression form at the doctor"
   ],
   "value_usd": 5.01,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A brief standardized questionnaire, scored and recorded during a visit — the paper or tablet form a clinic hands you about mood, anxiety or attention. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.15 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000 — the sum of 0.0 work + 0.14 non-facility practice expense + 0.01 malpractice. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $22.81 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 96127",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 22.81,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 4.46,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=96127, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 955088,
    "cy2024_rendering_providers": 38264,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number."
   },
   "audit": {
    "id": "cms-96127",
    "status": "PASS",
    "value_usd": 5.01,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 22.81,
      "evidence": "Avg_Sbmtd_Chrg = $22.81 on the National office row for 96127, alongside 955,088 services from 38,264 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 4.46,
      "evidence": "Avg_Mdcr_Alowd_Amt = $4.46 on the National office row for 96127, alongside 955,088 services from 38,264 providers"
     }
    ],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 96127",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.15 total non-facility RVUs x $33.4009 = $5.01",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-96156",
   "label": "Health behavior assessment with a clinician",
   "plain_language_synonyms": [
    "health behavior assessment",
    "saw a health psychologist",
    "behavioral health assessment",
    "assessment of how I am coping",
    "coping assessment"
   ],
   "value_usd": 107.55,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A clinician assesses the psychological and behavioral factors affecting a physical health problem — how you are coping with the illness itself, not a psychiatric diagnosis. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.22 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000 — the sum of 2.4 work + 0.8 non-facility practice expense + 0.02 malpractice. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $287.66 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 96156",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 287.66,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 90.66,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=96156, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 11773,
    "cy2024_rendering_providers": 875,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_physician_payment_usd": 86.84,
    "facility_setting_total_rvu": 2.6,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 2.60 facility total RVUs x $33.4009 = $86.84. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-96156",
    "status": "PASS",
    "value_usd": 107.55,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 287.66,
      "evidence": "Avg_Sbmtd_Chrg = $287.66 on the National office row for 96156, alongside 11,773 services from 875 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 90.66,
      "evidence": "Avg_Mdcr_Alowd_Amt = $90.66 on the National office row for 96156, alongside 11,773 services from 875 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 86.84,
      "evidence": "2.60 facility total RVUs on the unmodified line for 96156 x $33.4009 = $86.84"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 96156",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.22 total non-facility RVUs x $33.4009 = $107.55",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-99495",
   "label": "Transitional care after a hospital stay, moderate complexity",
   "plain_language_synonyms": [
    "transitional care",
    "follow-up after the hospital",
    "care after discharge",
    "post-discharge follow-up",
    "they called me after I got out of the hospital",
    "visit within two weeks of leaving the hospital"
   ],
   "value_usd": 220.11,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The follow-up a clinician bills for managing the first 30 days after you leave a hospital: contact within two business days and a face-to-face visit within 14 days. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 6.59 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000 — the sum of 2.78 work + 3.62 non-facility practice expense + 0.19 malpractice. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $411.48 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "CPT 99495",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 411.48,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 182.49,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=99495, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 692449,
    "cy2024_rendering_providers": 95133,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_physician_payment_usd": 122.25,
    "facility_setting_total_rvu": 3.66,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 3.66 facility total RVUs x $33.4009 = $122.25. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-99495",
    "status": "PASS",
    "value_usd": 220.11,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 411.48,
      "evidence": "Avg_Sbmtd_Chrg = $411.48 on the National office row for 99495, alongside 692,449 services from 95,133 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 182.49,
      "evidence": "Avg_Mdcr_Alowd_Amt = $182.49 on the National office row for 99495, alongside 692,449 services from 95,133 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 122.25,
      "evidence": "3.66 facility total RVUs on the unmodified line for 99495 x $33.4009 = $122.25"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "CPT 99495",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "6.59 total non-facility RVUs x $33.4009 = $220.11",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-g0442",
   "label": "Yearly alcohol misuse screening at a visit",
   "plain_language_synonyms": [
    "alcohol screening",
    "asked about my drinking",
    "annual alcohol screen",
    "alcohol misuse screening"
   ],
   "value_usd": 18.7,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The annual 5-to-15-minute alcohol misuse screening Medicare covers as a preventive service. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.56 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000 — the sum of 0.18 work + 0.37 non-facility practice expense + 0.01 malpractice. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $40.74 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "HCPCS G0442",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 40.74,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 18.01,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=G0442, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 1002324,
    "cy2024_rendering_providers": 17920,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_physician_payment_usd": 8.02,
    "facility_setting_total_rvu": 0.24,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 0.24 facility total RVUs x $33.4009 = $8.02. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "max_per_year": 1,
   "max_per_year_basis": "CMS’s own long descriptor for this code, read in the CY2024 claims file: “Annual alcohol misuse screening, 5 to 15 minutes”. Medicare pays it once in a 12-month period, so a count above one is counted and not priced.",
   "audit": {
    "id": "cms-g0442",
    "status": "PASS",
    "value_usd": 18.7,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 40.74,
      "evidence": "Avg_Sbmtd_Chrg = $40.74 on the National office row for G0442, alongside 1,002,324 services from 17,920 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 18.01,
      "evidence": "Avg_Mdcr_Alowd_Amt = $18.01 on the National office row for G0442, alongside 1,002,324 services from 17,920 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 8.02,
      "evidence": "0.24 facility total RVUs on the unmodified line for G0442 x $33.4009 = $8.02"
     }
    ],
    "frequency": [
     {
      "key": "max_per_year",
      "status": "PASS",
      "value_usd": null,
      "evidence": "CMS long descriptor for G0442: 'Annual alcohol misuse screening, 5 to 15 minutes'"
     }
    ],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "HCPCS G0442",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.56 total non-facility RVUs x $33.4009 = $18.70",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-g0444",
   "label": "Yearly depression screening at a visit",
   "plain_language_synonyms": [
    "depression screening",
    "screened for depression",
    "annual depression screen",
    "they screened me for depression"
   ],
   "value_usd": 18.7,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The annual 5-to-15-minute depression screening Medicare covers as a preventive service, in a setting that can follow up on the result. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.56 Total RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic indices of 1.000 — the sum of 0.18 work + 0.37 non-facility practice expense + 0.01 malpractice. Both inputs were read in the CMS file; the multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider's charge instead, which is shown beside this figure where CMS publishes it. For scale, the average CHARGE providers submitted for this same service in 2024 was $40.78 — that is what an uninsured person is billed against, and it is a different kind of number, not an addition to this one.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "DERIVED",
   "code": "HCPCS G0444",
   "agency": "CMS",
   "agency_display": "CMS",
   "alternates": {
    "cy2024_average_submitted_charge_usd": 40.78,
    "_charge_note": "CHARGE basis. An alternative measure of the same service, never an addition to it.",
    "cy2024_average_allowed_usd": 17.85,
    "_allowed_note": "What Medicare actually allowed on average in CY2024, read in the claims file. It differs from the 2026 schedule rate because many localities have cost indices below 1.000, because nurse practitioners and physician assistants are paid 85 percent of the physician rate and are inside this average, and because the two figures are two years apart. Neither is wrong.",
    "cy2024_source_title": "CMS, Medicare Physician & Other Practitioners — by Geography and Service, calendar year 2024 (released 2026-05)",
    "cy2024_source_url": "https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service",
    "cy2024_source_file": "MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_url": "https://data.cms.gov/sites/default/files/2026-05/e534c74b-79b8-4892-8a95-5a17e2dfec9f/MUP_PHY_R26_P05_V10_D24_Geo.csv",
    "cy2024_source_file_sha256": "c26956788333d03c0080017121c19e8e4d9990e9fa8ff385d7e1a2849c45074a",
    "cy2024_source_row": "Rndrng_Prvdr_Geo_Lvl=National, HCPCS_Cd=G0444, Place_Of_Srvc=O",
    "cy2024_place_of_service": "O — provider office / non-facility setting",
    "cy2024_retrieved": "2026-09-09",
    "cy2024_charge_field": "Avg_Sbmtd_Chrg",
    "cy2024_allowed_field": "Avg_Mdcr_Alowd_Amt",
    "cy2024_total_services": 2560500,
    "cy2024_rendering_providers": 48370,
    "cy2024_method": "READ, not computed. CMS publishes one National row per HCPCS code per place of service in this file, and this figure is that row's field, rounded to the cent. Nothing is averaged, weighted or adjusted here. Open the file, filter to the row named above, and you will see the same number.",
    "facility_setting_physician_payment_usd": 8.02,
    "facility_setting_total_rvu": 0.24,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 0.24 facility total RVUs x $33.4009 = $8.02. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "max_per_year": 1,
   "max_per_year_basis": "CMS’s own long descriptor for this code, read in the CY2024 claims file: “Annual depression screening, 5 to 15 minutes”. Medicare pays it once in a 12-month period, so a count above one is counted and not priced.",
   "audit": {
    "id": "cms-g0444",
    "status": "PASS",
    "value_usd": 18.7,
    "basis": "allowed_amount",
    "alternates": [
     {
      "key": "cy2024_average_submitted_charge_usd",
      "status": "PASS",
      "value_usd": 40.78,
      "evidence": "Avg_Sbmtd_Chrg = $40.78 on the National office row for G0444, alongside 2,560,500 services from 48,370 providers"
     },
     {
      "key": "cy2024_average_allowed_usd",
      "status": "PASS",
      "value_usd": 17.85,
      "evidence": "Avg_Mdcr_Alowd_Amt = $17.85 on the National office row for G0444, alongside 2,560,500 services from 48,370 providers"
     }
    ],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 8.02,
      "evidence": "0.24 facility total RVUs on the unmodified line for G0444 x $33.4009 = $8.02"
     }
    ],
    "frequency": [
     {
      "key": "max_per_year",
      "status": "PASS",
      "value_usd": null,
      "evidence": "CMS long descriptor for G0444: 'Annual depression screening, 5 to 15 minutes'"
     }
    ],
    "confidence": "DERIVED",
    "agency": "CMS",
    "code": "HCPCS G0444",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.56 total non-facility RVUs x $33.4009 = $18.70",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-99401",
   "label": "Preventive counseling visit, about 15 minutes",
   "plain_language_synonyms": [
    "counseling visit",
    "preventive counseling",
    "lifestyle counseling",
    "talked with my doctor about diet and exercise"
   ],
   "value_usd": null,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": false,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "This is a preventive counseling visit of about 15 minutes. HOW THIS NUMBER WAS MADE: it was not, and that is the finding. CMS publishes Relative Value Units for CPT 99401 in the CY2026 Physician Fee Schedule Relative Value File — 0.48 work, 0.68 non-facility practice expense, 0.03 malpractice — but the same row carries status indicator N, which the file defines as a non-covered service. Medicare pays nothing for it, so multiplying those units by the conversion factor would produce a number Medicare never pays. The CY2024 claims file publishes no national figure for this code either. This line is named and left blank rather than filled with arithmetic. Who this describes: nobody — no federal file publishes a price for this service. Who it does NOT describe: everyone. If you had this visit, the amount you were billed came from your provider's own charge or your plan's negotiated rate, and neither is published anywhere in the federal data this tool reads.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "VERIFIED",
   "code": "CPT 99401",
   "agency": "CMS",
   "agency_display": "CMS",
   "pfs_status_indicator": "N",
   "audit": {
    "id": "cms-99401",
    "status": "PASS",
    "value_usd": null,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 99401",
    "loinc": null,
    "check": "PFS status indicator, read in the file",
    "evidence": "99401 carries status N — non-covered. CMS publishes 0.48 work, 0.68 non-facility practice expense and 0.03 malpractice RVUs for it and pays nothing, so this row carries no figure",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-99408",
   "label": "Alcohol or drug screening with a brief intervention, 15 to 30 minutes",
   "plain_language_synonyms": [
    "SBIRT",
    "brief intervention",
    "substance use screening with counseling",
    "screening and counseling about drinking or drugs"
   ],
   "value_usd": null,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": false,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "This is a structured substance-use screening with a brief intervention, 15 to 30 minutes. HOW THIS NUMBER WAS MADE: it was not, and that is the finding. CMS publishes Relative Value Units for CPT 99408 in the CY2026 Physician Fee Schedule Relative Value File — 0.65 work, 0.36 non-facility practice expense, 0.04 malpractice — but the same row carries status indicator N, which the file defines as a non-covered service. Medicare pays nothing for it, so multiplying those units by the conversion factor would produce a number Medicare never pays. The CY2024 claims file publishes no national figure for this code either. This line is named and left blank rather than filled with arithmetic. Who this describes: nobody — no federal file publishes a price for this service. Who it does NOT describe: everyone. If you had this visit, the amount you were billed came from your provider's own charge or your plan's negotiated rate, and neither is published anywhere in the federal data this tool reads.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "confidence": "VERIFIED",
   "code": "CPT 99408",
   "agency": "CMS",
   "agency_display": "CMS",
   "pfs_status_indicator": "N",
   "audit": {
    "id": "cms-99408",
    "status": "PASS",
    "value_usd": null,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "CMS",
    "code": "CPT 99408",
    "loinc": null,
    "check": "PFS status indicator, read in the file",
    "evidence": "99408 carries status N — non-covered. CMS publishes 0.65 work, 0.36 non-facility practice expense and 0.04 malpractice RVUs for it and pays nothing, so this row carries no figure",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-ed-99281-physician",
   "label": "Emergency room — the DOCTOR’s half only, level 1 (nurse-level problem)",
   "plain_language_synonyms": [
    "er doctor fee level 1",
    "emergency physician bill level one",
    "er doctor charge minor problem",
    "emergency room physician fee lowest level",
    "er physician professional fee level 1",
    "doctor’s bill from the emergency room, minor"
   ],
   "value_usd": 11.02,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The emergency physician’s fee for the least complex emergency department visit — a problem that may not have required a physician at all. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.33 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.25 work + 0.05 non-facility practice expense + 0.03 malpractice RVUs, all four figures read in the CMS file on the line for CPT 99281 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the emergency physician’s fee only. The hospital bills its own separate emergency department facility fee, which is not in this figure and is usually the larger of the two. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 99281",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-ed-99281-physician",
    "status": "PASS",
    "value_usd": 11.02,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 99281",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.33 total non-facility RVUs x $33.4009 = $11.02",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-ed-99282-physician",
   "label": "Emergency room — the DOCTOR’s half only, level 2 (straightforward)",
   "plain_language_synonyms": [
    "er doctor fee level 2",
    "emergency physician bill level two",
    "er physician professional fee straightforward",
    "emergency room doctor charge level 2",
    "er doctor’s bill straightforward problem",
    "emergency physician fee low level"
   ],
   "value_usd": 40.42,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The emergency physician’s fee for a straightforward emergency department visit. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.21 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.93 work + 0.17 non-facility practice expense + 0.11 malpractice RVUs, all four figures read in the CMS file on the line for CPT 99282 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the emergency physician’s fee only. The hospital bills its own separate emergency department facility fee, which is not in this figure and is usually the larger of the two. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 99282",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-ed-99282-physician",
    "status": "PASS",
    "value_usd": 40.42,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 99282",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.21 total non-facility RVUs x $33.4009 = $40.42",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-ed-99283-physician",
   "label": "Emergency room — the DOCTOR’s half only, level 3 (low complexity)",
   "plain_language_synonyms": [
    "er doctor fee level 3",
    "emergency physician bill level three",
    "er physician professional fee low complexity",
    "emergency room doctor charge level 3",
    "er doctor’s bill low complexity",
    "emergency physician fee level three"
   ],
   "value_usd": 69.47,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The emergency physician’s fee for an emergency department visit of low medical complexity. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 2.08 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.60 work + 0.28 non-facility practice expense + 0.20 malpractice RVUs, all four figures read in the CMS file on the line for CPT 99283 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the emergency physician’s fee only. The hospital bills its own separate emergency department facility fee, which is not in this figure and is usually the larger of the two. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 99283",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-ed-99283-physician",
    "status": "PASS",
    "value_usd": 69.47,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 99283",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "2.08 total non-facility RVUs x $33.4009 = $69.47",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-ed-99285-physician",
   "label": "Emergency room — the DOCTOR’s half only, level 5 (highest complexity)",
   "plain_language_synonyms": [
    "er doctor fee level 5",
    "emergency physician bill level five",
    "er physician professional fee high complexity",
    "emergency room doctor charge level 5",
    "er doctor’s bill for a serious emergency",
    "emergency physician fee highest level"
   ],
   "value_usd": 171.35,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The emergency physician’s fee for the most complex emergency department visit, short of critical care. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 5.13 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 4.00 work + 0.65 non-facility practice expense + 0.48 malpractice RVUs, all four figures read in the CMS file on the line for CPT 99285 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the emergency physician’s fee only. The hospital bills its own separate emergency department facility fee, which is not in this figure and is usually the larger of the two. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 99285",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-ed-99285-physician",
    "status": "PASS",
    "value_usd": 171.35,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 99285",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "5.13 total non-facility RVUs x $33.4009 = $171.35",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-98016",
   "label": "Quick check-in by phone or video with a doctor who already knows you",
   "plain_language_synonyms": [
    "brief virtual check in",
    "five minute phone check in with my doctor",
    "quick video check in",
    "virtual check in with my clinic",
    "short telehealth check in",
    "brief communication technology based service"
   ],
   "value_usd": 17.37,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A brief, 5 to 10 minute check-in by phone, video or portal with a clinician who has seen you before, not leading to a visit. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.52 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.30 work + 0.20 non-facility practice expense + 0.02 malpractice RVUs, all four figures read in the CMS file on the line for CPT 98016 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 98016",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 13.03,
    "facility_setting_total_rvu": 0.39,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 0.39 facility total RVUs x $33.4009 = $13.03. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-98016",
    "status": "PASS",
    "value_usd": 17.37,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 13.03,
      "evidence": "0.39 facility total RVUs on the unmodified line for 98016 x $33.4009 = $13.03"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 98016",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.52 total non-facility RVUs x $33.4009 = $17.37",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-g0438",
   "label": "Medicare annual wellness visit, the first one",
   "plain_language_synonyms": [
    "first annual wellness visit",
    "medicare wellness visit initial",
    "yearly medicare check up first time",
    "initial annual wellness visit",
    "medicare annual wellness exam first",
    "first yearly wellness visit"
   ],
   "value_usd": 174.35,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The first Medicare annual wellness visit, where a personalised prevention plan is written. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 5.22 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 2.60 work + 2.45 non-facility practice expense + 0.17 malpractice RVUs, all four figures read in the CMS file on the line for HCPCS G0438 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "HCPCS G0438",
   "pfs_status_indicator": "A",
   "max_per_year": 1,
   "max_per_year_basis": "CMS’s own long descriptor for this code, read in the CY2024 claims file: “Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit”. Medicare pays it once in a 12-month period, so a count above one is counted and not priced.",
   "audit": {
    "id": "cms-g0438",
    "status": "PASS",
    "value_usd": 174.35,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [
     {
      "key": "max_per_year",
      "status": "PASS",
      "value_usd": null,
      "evidence": "CMS long descriptor for G0438: 'Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit'"
     }
    ],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "HCPCS G0438",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "5.22 total non-facility RVUs x $33.4009 = $174.35",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-g0439",
   "label": "Medicare annual wellness visit, each year after the first",
   "plain_language_synonyms": [
    "subsequent annual wellness visit",
    "yearly medicare wellness check up",
    "annual wellness visit follow up year",
    "medicare wellness visit subsequent",
    "each year medicare wellness visit",
    "repeat annual wellness visit"
   ],
   "value_usd": 137.61,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The Medicare annual wellness visit in every year after the first one. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 4.12 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.92 work + 2.07 non-facility practice expense + 0.13 malpractice RVUs, all four figures read in the CMS file on the line for HCPCS G0439 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "HCPCS G0439",
   "pfs_status_indicator": "A",
   "max_per_year": 1,
   "max_per_year_basis": "CMS’s own long descriptor for this code, read in the CY2024 claims file: “Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit”. Medicare pays it once in a 12-month period, so a count above one is counted and not priced.",
   "audit": {
    "id": "cms-g0439",
    "status": "PASS",
    "value_usd": 137.61,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [
     {
      "key": "max_per_year",
      "status": "PASS",
      "value_usd": null,
      "evidence": "CMS long descriptor for G0439: 'Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit'"
     }
    ],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "HCPCS G0439",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "4.12 total non-facility RVUs x $33.4009 = $137.61",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-99483",
   "label": "Full memory and thinking assessment with a written care plan",
   "plain_language_synonyms": [
    "cognitive impairment assessment and care plan",
    "dementia evaluation visit",
    "memory clinic assessment",
    "full cognitive assessment appointment",
    "assessment for memory loss with care plan",
    "cognitive care planning visit"
   ],
   "value_usd": 292.93,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A long visit dedicated to assessing memory and thinking problems and writing a care plan for them. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 8.77 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 3.84 work + 4.66 non-facility practice expense + 0.27 malpractice RVUs, all four figures read in the CMS file on the line for CPT 99483 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 99483",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 169.68,
    "facility_setting_total_rvu": 5.08,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 5.08 facility total RVUs x $33.4009 = $169.68. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-99483",
    "status": "PASS",
    "value_usd": 292.93,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 169.68,
      "evidence": "5.08 facility total RVUs on the unmodified line for 99483 x $33.4009 = $169.68"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 99483",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "8.77 total non-facility RVUs x $33.4009 = $292.93",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-mh-therapy-30",
   "label": "Therapy session, 30 minutes",
   "plain_language_synonyms": [
    "half hour therapy session",
    "short therapy session",
    "thirty minute counselling session",
    "brief psychotherapy session",
    "30 minute session with my therapist",
    "short session with my counsellor"
   ],
   "value_usd": 85.84,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A 30-minute psychotherapy session with a patient. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 2.57 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.94 work + 0.62 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 90832 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 90832",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 69.47,
    "facility_setting_total_rvu": 2.08,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 2.08 facility total RVUs x $33.4009 = $69.47. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-mh-therapy-30",
    "status": "PASS",
    "value_usd": 85.84,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 69.47,
      "evidence": "2.08 facility total RVUs on the unmodified line for 90832 x $33.4009 = $69.47"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 90832",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "2.57 total non-facility RVUs x $33.4009 = $85.84",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-mh-psych-eval-meds",
   "label": "First appointment with a psychiatrist, including medication decisions",
   "plain_language_synonyms": [
    "psychiatric evaluation with medication management",
    "psychiatry intake with medication",
    "first psychiatrist appointment with prescribing",
    "diagnostic psychiatric evaluation with medical services",
    "psych eval with meds",
    "initial psychiatry visit with medication review"
   ],
   "value_usd": 202.08,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A first psychiatric diagnostic evaluation that also includes medical services such as prescribing. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 6.05 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 4.16 work + 1.72 non-facility practice expense + 0.17 malpractice RVUs, all four figures read in the CMS file on the line for CPT 90792 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 90792",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 159.32,
    "facility_setting_total_rvu": 4.77,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 4.77 facility total RVUs x $33.4009 = $159.32. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-mh-psych-eval-meds",
    "status": "PASS",
    "value_usd": 202.08,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 159.32,
      "evidence": "4.77 facility total RVUs on the unmodified line for 90792 x $33.4009 = $159.32"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 90792",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "6.05 total non-facility RVUs x $33.4009 = $202.08",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-mh-family-therapy",
   "label": "Family therapy session with the patient in the room, 50 minutes",
   "plain_language_synonyms": [
    "family therapy session",
    "couples therapy session",
    "family counselling with me present",
    "conjoint family psychotherapy",
    "family session with my therapist",
    "therapy with my partner present"
   ],
   "value_usd": 109.55,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A 50-minute family psychotherapy session with the patient present. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.28 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 2.86 work + 0.40 non-facility practice expense + 0.02 malpractice RVUs, all four figures read in the CMS file on the line for CPT 90847 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 90847",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 102.87,
    "facility_setting_total_rvu": 3.08,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 3.08 facility total RVUs x $33.4009 = $102.87. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-mh-family-therapy",
    "status": "PASS",
    "value_usd": 109.55,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 102.87,
      "evidence": "3.08 facility total RVUs on the unmodified line for 90847 x $33.4009 = $102.87"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 90847",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.28 total non-facility RVUs x $33.4009 = $109.55",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-mh-group-therapy",
   "label": "Group therapy session",
   "plain_language_synonyms": [
    "group therapy",
    "group counselling session",
    "support group run by a therapist",
    "group psychotherapy session",
    "therapy group meeting",
    "group session with a psychologist"
   ],
   "value_usd": 30.39,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A psychotherapy session delivered to a group. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.91 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.67 work + 0.23 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 90853 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 90853",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 24.38,
    "facility_setting_total_rvu": 0.73,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 0.73 facility total RVUs x $33.4009 = $24.38. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-mh-group-therapy",
    "status": "PASS",
    "value_usd": 30.39,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 24.38,
      "evidence": "0.73 facility total RVUs on the unmodified line for 90853 x $33.4009 = $24.38"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 90853",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.91 total non-facility RVUs x $33.4009 = $30.39",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-mh-crisis-60",
   "label": "Crisis therapy session, first 60 minutes",
   "plain_language_synonyms": [
    "crisis therapy session",
    "emergency counselling session",
    "psychiatric crisis visit",
    "urgent mental health session",
    "crisis psychotherapy first hour",
    "emergency session with my therapist"
   ],
   "value_usd": 160.32,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A psychotherapy session for a patient in crisis, first 60 minutes. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 4.80 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 3.58 work + 1.19 non-facility practice expense + 0.03 malpractice RVUs, all four figures read in the CMS file on the line for CPT 90839 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 90839",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 129.6,
    "facility_setting_total_rvu": 3.88,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 3.88 facility total RVUs x $33.4009 = $129.60. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-mh-crisis-60",
    "status": "PASS",
    "value_usd": 160.32,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 129.6,
      "evidence": "3.88 facility total RVUs on the unmodified line for 90839 x $33.4009 = $129.60"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 90839",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "4.80 total non-facility RVUs x $33.4009 = $160.32",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-psych-testing-1h",
   "label": "Psychological testing evaluation by a clinician, first hour",
   "plain_language_synonyms": [
    "psychological testing evaluation",
    "psych testing first hour",
    "clinician time for psychological testing",
    "psychological test interpretation hour",
    "testing evaluation by a psychologist",
    "psychological assessment interpretation"
   ],
   "value_usd": 123.92,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The clinician’s own time evaluating, interpreting and reporting psychological testing, first hour. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.71 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 2.56 work + 1.06 non-facility practice expense + 0.09 malpractice RVUs, all four figures read in the CMS file on the line for CPT 96130 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 96130",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 99.53,
    "facility_setting_total_rvu": 2.98,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 2.98 facility total RVUs x $33.4009 = $99.53. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-test-psych-testing-1h",
    "status": "PASS",
    "value_usd": 123.92,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 99.53,
      "evidence": "2.98 facility total RVUs on the unmodified line for 96130 x $33.4009 = $99.53"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 96130",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.71 total non-facility RVUs x $33.4009 = $123.92",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-pt-eval-mod",
   "label": "Physical therapy evaluation, moderate complexity",
   "plain_language_synonyms": [
    "physical therapy evaluation moderate",
    "pt evaluation moderate complexity",
    "physio assessment moderate complexity",
    "30 minute physical therapy evaluation",
    "moderate complexity pt eval",
    "physical therapy initial assessment moderate"
   ],
   "value_usd": 97.86,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A physical therapy evaluation of moderate complexity, typically about 30 minutes. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 2.93 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.54 work + 1.38 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 97162 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 97162",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-pt-eval-mod",
    "status": "PASS",
    "value_usd": 97.86,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 97162",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "2.93 total non-facility RVUs x $33.4009 = $97.86",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-pt-eval-high",
   "label": "Physical therapy evaluation, high complexity",
   "plain_language_synonyms": [
    "physical therapy evaluation high complexity",
    "pt evaluation high complexity",
    "complex physical therapy assessment",
    "45 minute physical therapy evaluation",
    "high complexity pt eval",
    "physical therapy initial assessment complex"
   ],
   "value_usd": 97.86,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A physical therapy evaluation of high complexity, typically about 45 minutes. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 2.93 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.54 work + 1.38 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 97163 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 97163",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-pt-eval-high",
    "status": "PASS",
    "value_usd": 97.86,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 97163",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "2.93 total non-facility RVUs x $33.4009 = $97.86",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-pt-manual-therapy-15",
   "label": "Hands-on manual therapy in a therapy session, 15 minutes",
   "plain_language_synonyms": [
    "manual therapy",
    "hands on therapy session",
    "myofascial release session",
    "joint mobilisation therapy",
    "manual therapy techniques 15 minutes",
    "soft tissue mobilisation"
   ],
   "value_usd": 27.72,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "Fifteen minutes of hands-on manual therapy — mobilisation, manipulation, myofascial release — within a therapy visit. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.83 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.43 work + 0.39 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 97140 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 97140",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-pt-manual-therapy-15",
    "status": "PASS",
    "value_usd": 27.72,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 97140",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.83 total non-facility RVUs x $33.4009 = $27.72",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-pt-neuro-reeducation-15",
   "label": "Balance and coordination retraining in therapy, 15 minutes",
   "plain_language_synonyms": [
    "neuromuscular reeducation",
    "balance retraining session",
    "coordination training in therapy",
    "proprioception training",
    "vestibular rehab exercises",
    "neuro re-education 15 minutes"
   ],
   "value_usd": 32.73,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "Fifteen minutes of neuromuscular re-education — balance, coordination, posture and proprioception training. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.98 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.50 work + 0.47 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 97112 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 97112",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-pt-neuro-reeducation-15",
    "status": "PASS",
    "value_usd": 32.73,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 97112",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.98 total non-facility RVUs x $33.4009 = $32.73",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-pt-therapeutic-activities-15",
   "label": "Functional activity training in therapy, 15 minutes",
   "plain_language_synonyms": [
    "therapeutic activities",
    "functional training in therapy",
    "activity based therapy session",
    "dynamic activities in physical therapy",
    "therapeutic activity 15 minutes",
    "functional task training"
   ],
   "value_usd": 35.07,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "Fifteen minutes of therapeutic activities using dynamic, functional tasks to improve performance. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.05 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.44 work + 0.60 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 97530 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 97530",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-pt-therapeutic-activities-15",
    "status": "PASS",
    "value_usd": 35.07,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 97530",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.05 total non-facility RVUs x $33.4009 = $35.07",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-ot-eval-low",
   "label": "Occupational therapy evaluation, low complexity",
   "plain_language_synonyms": [
    "occupational therapy evaluation",
    "ot evaluation low complexity",
    "first occupational therapy appointment",
    "occupational therapy assessment",
    "ot initial evaluation",
    "occupational therapy intake evaluation"
   ],
   "value_usd": 100.54,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An occupational therapy evaluation of low complexity, typically about 30 minutes. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.01 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.54 work + 1.46 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 97165 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 97165",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-ot-eval-low",
    "status": "PASS",
    "value_usd": 100.54,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 97165",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.01 total non-facility RVUs x $33.4009 = $100.54",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-ot-eval-high",
   "label": "Occupational therapy evaluation, high complexity",
   "plain_language_synonyms": [
    "occupational therapy evaluation high complexity",
    "ot evaluation high complexity",
    "complex occupational therapy assessment",
    "60 minute occupational therapy evaluation",
    "high complexity ot eval",
    "occupational therapy assessment complex"
   ],
   "value_usd": 100.54,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An occupational therapy evaluation of high complexity, typically about 60 minutes. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.01 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.54 work + 1.46 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 97167 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 97167",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-ot-eval-high",
    "status": "PASS",
    "value_usd": 100.54,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 97167",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.01 total non-facility RVUs x $33.4009 = $100.54",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-speech-therapy",
   "label": "Speech and language therapy session, one person",
   "plain_language_synonyms": [
    "speech therapy session",
    "speech and language therapy",
    "saw a speech therapist",
    "slp session",
    "speech pathology treatment session",
    "individual speech therapy"
   ],
   "value_usd": 76.15,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An individual treatment session for a speech, language, voice or communication disorder. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 2.28 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.30 work + 0.97 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 92507 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 92507",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-speech-therapy",
    "status": "PASS",
    "value_usd": 76.15,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 92507",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "2.28 total non-facility RVUs x $33.4009 = $76.15",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-chiro-3-4-regions",
   "label": "Chiropractic adjustment, three or four areas of the spine",
   "plain_language_synonyms": [
    "chiropractic adjustment",
    "went to the chiropractor",
    "spinal manipulation by a chiropractor",
    "chiro adjustment three regions",
    "chiropractic manipulation session",
    "adjustment at the chiropractor"
   ],
   "value_usd": 38.41,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A chiropractic spinal manipulation covering three to four spinal regions. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.15 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.69 work + 0.45 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 98941 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 98941",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 28.06,
    "facility_setting_total_rvu": 0.84,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 0.84 facility total RVUs x $33.4009 = $28.06. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-chiro-3-4-regions",
    "status": "PASS",
    "value_usd": 38.41,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 28.06,
      "evidence": "0.84 facility total RVUs on the unmodified line for 98941 x $33.4009 = $28.06"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 98941",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.15 total non-facility RVUs x $33.4009 = $38.41",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-acupuncture-15",
   "label": "Acupuncture, first 15 minutes",
   "plain_language_synonyms": [
    "acupuncture session",
    "acupuncture treatment",
    "first 15 minutes of acupuncture",
    "dry needling by an acupuncturist",
    "acupuncture without electrical stimulation",
    "went for acupuncture"
   ],
   "value_usd": 48.1,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "Acupuncture with one or more needles, first 15 minutes of personal contact, without electrical stimulation. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.44 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.61 work + 0.79 non-facility practice expense + 0.04 malpractice RVUs, all four figures read in the CMS file on the line for CPT 97810 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 97810",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 27.39,
    "facility_setting_total_rvu": 0.82,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 0.82 facility total RVUs x $33.4009 = $27.39. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-acupuncture-15",
    "status": "PASS",
    "value_usd": 48.1,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 27.39,
      "evidence": "0.82 facility total RVUs on the unmodified line for 97810 x $33.4009 = $27.39"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 97810",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.44 total non-facility RVUs x $33.4009 = $48.10",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-massage-therapy-15",
   "label": "Massage therapy in a therapy session, 15 minutes",
   "plain_language_synonyms": [
    "massage therapy",
    "therapeutic massage session",
    "massage in physical therapy",
    "effleurage massage treatment",
    "15 minutes of massage therapy",
    "clinical massage session"
   ],
   "value_usd": 29.73,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "Fifteen minutes of massage therapy delivered as part of a therapy plan. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.89 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.35 work + 0.53 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 97124 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 97124",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-massage-therapy-15",
    "status": "PASS",
    "value_usd": 29.73,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 97124",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.89 total non-facility RVUs x $33.4009 = $29.73",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-cxr-1view",
   "label": "Chest X-ray, one view",
   "plain_language_synonyms": [
    "single view chest x ray",
    "one view chest xray",
    "frontal chest x ray only",
    "chest film one view",
    "single chest radiograph",
    "portable chest x ray one view"
   ],
   "value_usd": 25.38,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A chest X-ray taken in a single view. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.76 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.18 work + 0.56 non-facility practice expense + 0.02 malpractice RVUs, all four figures read in the CMS file on the line for CPT 71045 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 71045",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 8.35,
    "facility_setting_total_rvu": 0.25,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 0.25 facility total RVUs on the modifier 26 line x $33.4009 = $8.35 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-cxr-1view",
    "status": "PASS",
    "value_usd": 25.38,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 8.35,
      "evidence": "0.25 facility total RVUs on the modifier 26 line for 71045 x $33.4009 = $8.35"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 71045",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.76 total non-facility RVUs x $33.4009 = $25.38",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-xray-knee-3",
   "label": "Knee X-ray, three views",
   "plain_language_synonyms": [
    "knee x ray",
    "x ray of my knee",
    "knee xray three views",
    "knee radiograph",
    "they x rayed my knee",
    "knee films"
   ],
   "value_usd": 42.42,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An X-ray of one knee taken in three views. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.27 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.18 work + 1.07 non-facility practice expense + 0.02 malpractice RVUs, all four figures read in the CMS file on the line for CPT 73562 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 73562",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 9.35,
    "facility_setting_total_rvu": 0.28,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 0.28 facility total RVUs on the modifier 26 line x $33.4009 = $9.35 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-xray-knee-3",
    "status": "PASS",
    "value_usd": 42.42,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 9.35,
      "evidence": "0.28 facility total RVUs on the modifier 26 line for 73562 x $33.4009 = $9.35"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 73562",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.27 total non-facility RVUs x $33.4009 = $42.42",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-xray-lumbar",
   "label": "Lower back X-ray, four or more views",
   "plain_language_synonyms": [
    "lower back x ray",
    "lumbar spine x ray",
    "x ray of my lower back",
    "back xray",
    "lumbar radiograph",
    "spine x ray lower"
   ],
   "value_usd": 53.44,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An X-ray of the lumbar spine taken in four or more views. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.60 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.25 work + 1.32 non-facility practice expense + 0.03 malpractice RVUs, all four figures read in the CMS file on the line for CPT 72110 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 72110",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 12.69,
    "facility_setting_total_rvu": 0.38,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 0.38 facility total RVUs on the modifier 26 line x $33.4009 = $12.69 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-xray-lumbar",
    "status": "PASS",
    "value_usd": 53.44,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 12.69,
      "evidence": "0.38 facility total RVUs on the modifier 26 line for 72110 x $33.4009 = $12.69"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 72110",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.60 total non-facility RVUs x $33.4009 = $53.44",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-xray-shoulder",
   "label": "Shoulder X-ray",
   "plain_language_synonyms": [
    "shoulder x ray",
    "x ray of my shoulder",
    "shoulder xray",
    "shoulder radiograph",
    "they x rayed my shoulder",
    "shoulder films"
   ],
   "value_usd": 35.74,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A complete X-ray of one shoulder. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.07 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.18 work + 0.87 non-facility practice expense + 0.02 malpractice RVUs, all four figures read in the CMS file on the line for CPT 73030 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 73030",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 9.02,
    "facility_setting_total_rvu": 0.27,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 0.27 facility total RVUs on the modifier 26 line x $33.4009 = $9.02 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-xray-shoulder",
    "status": "PASS",
    "value_usd": 35.74,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 9.02,
      "evidence": "0.27 facility total RVUs on the modifier 26 line for 73030 x $33.4009 = $9.02"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 73030",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.07 total non-facility RVUs x $33.4009 = $35.74",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-xray-hand",
   "label": "Hand X-ray",
   "plain_language_synonyms": [
    "hand x ray",
    "x ray of my hand",
    "hand xray",
    "x ray of my fingers",
    "hand radiograph",
    "they x rayed my hand"
   ],
   "value_usd": 38.08,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An X-ray of one hand in three or more views. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.14 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.17 work + 0.95 non-facility practice expense + 0.02 malpractice RVUs, all four figures read in the CMS file on the line for CPT 73130 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 73130",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 8.68,
    "facility_setting_total_rvu": 0.26,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 0.26 facility total RVUs on the modifier 26 line x $33.4009 = $8.68 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-xray-hand",
    "status": "PASS",
    "value_usd": 38.08,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 8.68,
      "evidence": "0.26 facility total RVUs on the modifier 26 line for 73130 x $33.4009 = $8.68"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 73130",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.14 total non-facility RVUs x $33.4009 = $38.08",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-xray-foot",
   "label": "Foot X-ray",
   "plain_language_synonyms": [
    "foot x ray",
    "x ray of my foot",
    "foot xray",
    "x ray of my toes",
    "foot radiograph",
    "they x rayed my foot"
   ],
   "value_usd": 34.07,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A complete X-ray of one foot. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.02 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.17 work + 0.83 non-facility practice expense + 0.02 malpractice RVUs, all four figures read in the CMS file on the line for CPT 73630 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 73630",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 8.02,
    "facility_setting_total_rvu": 0.24,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 0.24 facility total RVUs on the modifier 26 line x $33.4009 = $8.02 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-xray-foot",
    "status": "PASS",
    "value_usd": 34.07,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 8.02,
      "evidence": "0.24 facility total RVUs on the modifier 26 line for 73630 x $33.4009 = $8.02"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 73630",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.02 total non-facility RVUs x $33.4009 = $34.07",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-mri-cervical-nc",
   "label": "MRI of the neck part of the spine, without contrast",
   "plain_language_synonyms": [
    "neck mri",
    "cervical spine mri",
    "mri of my neck",
    "mri cervical spine without contrast",
    "neck spine scan",
    "mri of the upper spine"
   ],
   "value_usd": 190.72,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An MRI of the cervical spine performed without contrast dye. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 5.71 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.44 work + 4.17 non-facility practice expense + 0.10 malpractice RVUs, all four figures read in the CMS file on the line for CPT 72141 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 72141",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 68.14,
    "facility_setting_total_rvu": 2.04,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 2.04 facility total RVUs on the modifier 26 line x $33.4009 = $68.14 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-mri-cervical-nc",
    "status": "PASS",
    "value_usd": 190.72,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 68.14,
      "evidence": "2.04 facility total RVUs on the modifier 26 line for 72141 x $33.4009 = $68.14"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 72141",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "5.71 total non-facility RVUs x $33.4009 = $190.72",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-mri-upper-joint-nc",
   "label": "MRI of a shoulder, elbow or wrist, without contrast",
   "plain_language_synonyms": [
    "shoulder mri",
    "mri of my shoulder",
    "wrist mri",
    "elbow mri",
    "mri of an upper limb joint",
    "mri of my wrist without dye"
   ],
   "value_usd": 205.08,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An MRI of one upper-extremity joint performed without contrast dye. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 6.14 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.32 work + 4.73 non-facility practice expense + 0.09 malpractice RVUs, all four figures read in the CMS file on the line for CPT 73221 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 73221",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 63.13,
    "facility_setting_total_rvu": 1.89,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.89 facility total RVUs on the modifier 26 line x $33.4009 = $63.13 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-mri-upper-joint-nc",
    "status": "PASS",
    "value_usd": 205.08,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 63.13,
      "evidence": "1.89 facility total RVUs on the modifier 26 line for 73221 x $33.4009 = $63.13"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 73221",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "6.14 total non-facility RVUs x $33.4009 = $205.08",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-ct-abd-pelvis-nc",
   "label": "CT of the abdomen and pelvis, without contrast",
   "plain_language_synonyms": [
    "ct abdomen and pelvis without contrast",
    "cat scan of my belly without dye",
    "ct of my abdomen no contrast",
    "non contrast ct abdomen pelvis",
    "stone protocol ct",
    "ct scan belly and pelvis plain"
   ],
   "value_usd": 183.04,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A CT of the abdomen and pelvis performed without contrast dye. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 5.48 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.70 work + 3.67 non-facility practice expense + 0.11 malpractice RVUs, all four figures read in the CMS file on the line for CPT 74176 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 74176",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 79.83,
    "facility_setting_total_rvu": 2.39,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 2.39 facility total RVUs on the modifier 26 line x $33.4009 = $79.83 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-ct-abd-pelvis-nc",
    "status": "PASS",
    "value_usd": 183.04,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 79.83,
      "evidence": "2.39 facility total RVUs on the modifier 26 line for 74176 x $33.4009 = $79.83"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 74176",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "5.48 total non-facility RVUs x $33.4009 = $183.04",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-ct-sinus",
   "label": "CT of the sinuses",
   "plain_language_synonyms": [
    "sinus ct",
    "ct of my sinuses",
    "cat scan of my sinuses",
    "maxillofacial ct without dye",
    "sinus cat scan",
    "ct scan for sinus problems"
   ],
   "value_usd": 128.26,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A CT of the maxillofacial area, the scan used to look at the sinuses, without contrast. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.84 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.83 work + 2.95 non-facility practice expense + 0.06 malpractice RVUs, all four figures read in the CMS file on the line for CPT 70486 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 70486",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 39.75,
    "facility_setting_total_rvu": 1.19,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.19 facility total RVUs on the modifier 26 line x $33.4009 = $39.75 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-ct-sinus",
    "status": "PASS",
    "value_usd": 128.26,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 39.75,
      "evidence": "1.19 facility total RVUs on the modifier 26 line for 70486 x $33.4009 = $39.75"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 70486",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.84 total non-facility RVUs x $33.4009 = $128.26",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-ct-lumbar",
   "label": "CT of the lower back",
   "plain_language_synonyms": [
    "lumbar ct",
    "ct of my lower back",
    "cat scan of my lower spine",
    "ct lumbar spine without dye",
    "lower back cat scan",
    "ct scan of the lumbar spine"
   ],
   "value_usd": 129.93,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A CT of the lumbar spine performed without contrast dye. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.89 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.98 work + 2.84 non-facility practice expense + 0.07 malpractice RVUs, all four figures read in the CMS file on the line for CPT 72131 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 72131",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 46.43,
    "facility_setting_total_rvu": 1.39,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.39 facility total RVUs on the modifier 26 line x $33.4009 = $46.43 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-ct-lumbar",
    "status": "PASS",
    "value_usd": 129.93,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 46.43,
      "evidence": "1.39 facility total RVUs on the modifier 26 line for 72131 x $33.4009 = $46.43"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 72131",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.89 total non-facility RVUs x $33.4009 = $129.93",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-us-thyroid",
   "label": "Thyroid and neck ultrasound",
   "plain_language_synonyms": [
    "thyroid ultrasound",
    "ultrasound of my thyroid",
    "neck ultrasound for a lump",
    "thyroid sonogram",
    "ultrasound of a neck nodule",
    "soft tissue neck ultrasound"
   ],
   "value_usd": 108.55,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A complete ultrasound of the soft tissues of the head and neck, the study used for the thyroid. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.25 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.55 work + 2.66 non-facility practice expense + 0.04 malpractice RVUs, all four figures read in the CMS file on the line for CPT 76536 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 76536",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 26.39,
    "facility_setting_total_rvu": 0.79,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 0.79 facility total RVUs on the modifier 26 line x $33.4009 = $26.39 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-us-thyroid",
    "status": "PASS",
    "value_usd": 108.55,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 26.39,
      "evidence": "0.79 facility total RVUs on the modifier 26 line for 76536 x $33.4009 = $26.39"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 76536",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.25 total non-facility RVUs x $33.4009 = $108.55",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-us-breast",
   "label": "Breast ultrasound, complete",
   "plain_language_synonyms": [
    "breast ultrasound",
    "ultrasound of my breast",
    "breast sonogram",
    "complete breast ultrasound",
    "ultrasound for a breast lump",
    "sonogram of the breast"
   ],
   "value_usd": 100.2,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A complete ultrasound of one breast including the armpit. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.00 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.71 work + 2.24 non-facility practice expense + 0.05 malpractice RVUs, all four figures read in the CMS file on the line for CPT 76641 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 76641",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 33.73,
    "facility_setting_total_rvu": 1.01,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.01 facility total RVUs on the modifier 26 line x $33.4009 = $33.73 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-us-breast",
    "status": "PASS",
    "value_usd": 100.2,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 33.73,
      "evidence": "1.01 facility total RVUs on the modifier 26 line for 76641 x $33.4009 = $33.73"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 76641",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.00 total non-facility RVUs x $33.4009 = $100.20",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-us-kidneys",
   "label": "Kidney ultrasound, complete",
   "plain_language_synonyms": [
    "kidney ultrasound",
    "renal ultrasound",
    "ultrasound of my kidneys",
    "retroperitoneal ultrasound",
    "sonogram of the kidneys",
    "ultrasound to look at my kidneys"
   ],
   "value_usd": 106.21,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A complete ultrasound of the retroperitoneum, which is the study used to look at the kidneys. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.18 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.72 work + 2.41 non-facility practice expense + 0.05 malpractice RVUs, all four figures read in the CMS file on the line for CPT 76770 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 76770",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 34.07,
    "facility_setting_total_rvu": 1.02,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.02 facility total RVUs on the modifier 26 line x $33.4009 = $34.07 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-us-kidneys",
    "status": "PASS",
    "value_usd": 106.21,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 34.07,
      "evidence": "1.02 facility total RVUs on the modifier 26 line for 76770 x $33.4009 = $34.07"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 76770",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.18 total non-facility RVUs x $33.4009 = $106.21",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-us-transvaginal",
   "label": "Transvaginal ultrasound (not for pregnancy)",
   "plain_language_synonyms": [
    "transvaginal ultrasound",
    "internal ultrasound",
    "ultrasound wand internally",
    "tv ultrasound non obstetric",
    "internal pelvic ultrasound",
    "transvaginal sonogram"
   ],
   "value_usd": 117.57,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A transvaginal ultrasound performed for a non-pregnancy reason. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.52 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.67 work + 2.79 non-facility practice expense + 0.06 malpractice RVUs, all four figures read in the CMS file on the line for CPT 76830 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 76830",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 32.4,
    "facility_setting_total_rvu": 0.97,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 0.97 facility total RVUs on the modifier 26 line x $33.4009 = $32.40 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-us-transvaginal",
    "status": "PASS",
    "value_usd": 117.57,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 32.4,
      "evidence": "0.97 facility total RVUs on the modifier 26 line for 76830 x $33.4009 = $32.40"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 76830",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.52 total non-facility RVUs x $33.4009 = $117.57",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-mammo-screen",
   "label": "Screening mammogram, both breasts",
   "plain_language_synonyms": [
    "screening mammogram",
    "routine mammogram",
    "yearly mammogram",
    "mammogram both sides",
    "screening mammography with cad",
    "my annual mammogram"
   ],
   "value_usd": 126.26,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A screening mammogram of both breasts, including computer-aided detection. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.78 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.74 work + 2.99 non-facility practice expense + 0.05 malpractice RVUs, all four figures read in the CMS file on the line for CPT 77067 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 77067",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 35.07,
    "facility_setting_total_rvu": 1.05,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.05 facility total RVUs on the modifier 26 line x $33.4009 = $35.07 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-mammo-screen",
    "status": "PASS",
    "value_usd": 126.26,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 35.07,
      "evidence": "1.05 facility total RVUs on the modifier 26 line for 77067 x $33.4009 = $35.07"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 77067",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.78 total non-facility RVUs x $33.4009 = $126.26",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-mammo-dx-uni",
   "label": "Diagnostic mammogram, one breast",
   "plain_language_synonyms": [
    "diagnostic mammogram",
    "mammogram to check a lump",
    "callback mammogram one side",
    "unilateral diagnostic mammography",
    "follow up mammogram one breast",
    "mammogram because they found something"
   ],
   "value_usd": 123.92,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A diagnostic mammogram of one breast, including computer-aided detection. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.71 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.79 work + 2.86 non-facility practice expense + 0.06 malpractice RVUs, all four figures read in the CMS file on the line for CPT 77065 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 77065",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 37.74,
    "facility_setting_total_rvu": 1.13,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.13 facility total RVUs on the modifier 26 line x $33.4009 = $37.74 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-mammo-dx-uni",
    "status": "PASS",
    "value_usd": 123.92,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 37.74,
      "evidence": "1.13 facility total RVUs on the modifier 26 line for 77065 x $33.4009 = $37.74"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 77065",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.71 total non-facility RVUs x $33.4009 = $123.92",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-dexa",
   "label": "Bone density scan (DEXA)",
   "plain_language_synonyms": [
    "bone density scan",
    "dexa scan",
    "dxa bone density test",
    "osteoporosis scan",
    "bone mineral density test",
    "scan for thinning bones"
   ],
   "value_usd": 39.41,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A dual-energy X-ray absorptiometry study of the hip and spine, the standard bone density scan. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.18 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.20 work + 0.96 non-facility practice expense + 0.02 malpractice RVUs, all four figures read in the CMS file on the line for CPT 77080 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 77080",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 9.35,
    "facility_setting_total_rvu": 0.28,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 0.28 facility total RVUs on the modifier 26 line x $33.4009 = $9.35 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-dexa",
    "status": "PASS",
    "value_usd": 39.41,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 9.35,
      "evidence": "0.28 facility total RVUs on the modifier 26 line for 77080 x $33.4009 = $9.35"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 77080",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.18 total non-facility RVUs x $33.4009 = $39.41",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-cta-chest",
   "label": "CT angiogram of the chest (the scan for a blood clot in the lung)",
   "plain_language_synonyms": [
    "ct angiogram of my chest",
    "cta chest for a clot",
    "ct pulmonary angiogram",
    "scan to rule out a pulmonary embolism",
    "ctpa scan",
    "chest cta with dye"
   ],
   "value_usd": 280.57,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A CT angiogram of the chest, the study used to look for a clot in the lung arteries. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 8.40 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.77 work + 6.49 non-facility practice expense + 0.14 malpractice RVUs, all four figures read in the CMS file on the line for CPT 71275 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 71275",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 83.5,
    "facility_setting_total_rvu": 2.5,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 2.50 facility total RVUs on the modifier 26 line x $33.4009 = $83.50 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-cta-chest",
    "status": "PASS",
    "value_usd": 280.57,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 83.5,
      "evidence": "2.50 facility total RVUs on the modifier 26 line for 71275 x $33.4009 = $83.50"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 71275",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "8.40 total non-facility RVUs x $33.4009 = $280.57",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-mra-head",
   "label": "MR angiogram of the head, without contrast",
   "plain_language_synonyms": [
    "mra of my head",
    "brain mra",
    "mr angiogram of the head",
    "angiogram of my brain arteries by mri",
    "head mra without dye",
    "mri angiography of the brain"
   ],
   "value_usd": 214.77,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A magnetic resonance angiogram of the head, performed without contrast dye. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 6.43 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.17 work + 5.16 non-facility practice expense + 0.10 malpractice RVUs, all four figures read in the CMS file on the line for CPT 70544 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 70544",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 55.11,
    "facility_setting_total_rvu": 1.65,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.65 facility total RVUs on the modifier 26 line x $33.4009 = $55.11 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-mra-head",
    "status": "PASS",
    "value_usd": 214.77,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 55.11,
      "evidence": "1.65 facility total RVUs on the modifier 26 line for 70544 x $33.4009 = $55.11"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 70544",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "6.43 total non-facility RVUs x $33.4009 = $214.77",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-nuclear-stress",
   "label": "Nuclear stress test of the heart",
   "plain_language_synonyms": [
    "nuclear stress test",
    "myocardial perfusion scan",
    "spect heart scan",
    "stress test with dye injection",
    "cardiac nuclear imaging",
    "nuclear medicine heart scan"
   ],
   "value_usd": 427.87,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A multi-study SPECT myocardial perfusion imaging test, the nuclear version of a cardiac stress test. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 12.81 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.58 work + 11.10 non-facility practice expense + 0.13 malpractice RVUs, all four figures read in the CMS file on the line for CPT 78452 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 78452",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 74.48,
    "facility_setting_total_rvu": 2.23,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 2.23 facility total RVUs on the modifier 26 line x $33.4009 = $74.48 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-nuclear-stress",
    "status": "PASS",
    "value_usd": 427.87,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 74.48,
      "evidence": "2.23 facility total RVUs on the modifier 26 line for 78452 x $33.4009 = $74.48"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 78452",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "12.81 total non-facility RVUs x $33.4009 = $427.87",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-bone-scan",
   "label": "Whole-body bone scan",
   "plain_language_synonyms": [
    "bone scan",
    "whole body bone scan",
    "nuclear bone scan",
    "bone scintigraphy",
    "they injected tracer and scanned my bones",
    "full body bone imaging"
   ],
   "value_usd": 259.19,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A whole-body nuclear medicine bone imaging study. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 7.76 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.84 work + 6.84 non-facility practice expense + 0.08 malpractice RVUs, all four figures read in the CMS file on the line for CPT 78306 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 78306",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 38.75,
    "facility_setting_total_rvu": 1.16,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.16 facility total RVUs on the modifier 26 line x $33.4009 = $38.75 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-bone-scan",
    "status": "PASS",
    "value_usd": 259.19,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 38.75,
      "evidence": "1.16 facility total RVUs on the modifier 26 line for 78306 x $33.4009 = $38.75"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 78306",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "7.76 total non-facility RVUs x $33.4009 = $259.19",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-stress-tracing",
   "label": "Treadmill stress test — the tracing part only",
   "plain_language_synonyms": [
    "stress test tracing only",
    "treadmill test technical portion",
    "stress test facility portion",
    "cardiovascular stress test tracing",
    "exercise test tracing only",
    "stress test without the doctor’s reading"
   ],
   "value_usd": 39.08,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The tracing portion of an exercise stress test, without the physician’s supervision or interpretation, which are billed separately. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.17 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.00 work + 1.15 non-facility practice expense + 0.02 malpractice RVUs, all four figures read in the CMS file on the line for CPT 93017 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is only the tracing. The physician’s supervision and interpretation are billed separately under CPT 93016 and 93018, so a person who had one treadmill test may see more than one line on the bill. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 93017",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-test-stress-tracing",
    "status": "PASS",
    "value_usd": 39.08,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 93017",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.17 total non-facility RVUs x $33.4009 = $39.08",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-ecg-interp",
   "label": "Heart tracing (ECG) — the doctor’s reading only",
   "plain_language_synonyms": [
    "ecg interpretation only",
    "ekg reading by the doctor",
    "electrocardiogram report only",
    "ecg professional component",
    "doctor’s fee for reading my ekg",
    "ekg interpretation and report"
   ],
   "value_usd": 8.35,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The physician’s interpretation and written report of an electrocardiogram, without the tracing itself. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.25 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.17 work + 0.07 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 93010 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is only the reading. The tracing is billed separately under CPT 93005, which is why one ECG can appear twice on a bill. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 93010",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-test-ecg-interp",
    "status": "PASS",
    "value_usd": 8.35,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 93010",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.25 total non-facility RVUs x $33.4009 = $8.35",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-echo-no-doppler",
   "label": "Echocardiogram without Doppler, complete",
   "plain_language_synonyms": [
    "echo without doppler",
    "complete echocardiogram no doppler",
    "2d echo without flow study",
    "transthoracic echo without doppler",
    "basic echocardiogram",
    "heart ultrasound without doppler"
   ],
   "value_usd": 137.95,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A complete transthoracic echocardiogram performed without Doppler flow study. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 4.13 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.90 work + 3.18 non-facility practice expense + 0.05 malpractice RVUs, all four figures read in the CMS file on the line for CPT 93307 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 93307",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 43.09,
    "facility_setting_total_rvu": 1.29,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.29 facility total RVUs on the modifier 26 line x $33.4009 = $43.09 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-echo-no-doppler",
    "status": "PASS",
    "value_usd": 137.95,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 43.09,
      "evidence": "1.29 facility total RVUs on the modifier 26 line for 93307 x $33.4009 = $43.09"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 93307",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "4.13 total non-facility RVUs x $33.4009 = $137.95",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-tee",
   "label": "Echocardiogram from inside the throat (TEE)",
   "plain_language_synonyms": [
    "transesophageal echocardiogram",
    "tee heart test",
    "echo down my throat",
    "transoesophageal echo",
    "probe down the throat to look at my heart",
    "tee study"
   ],
   "value_usd": 239.48,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A transesophageal echocardiogram, including probe placement, image acquisition and interpretation. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 7.17 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 2.24 work + 4.83 non-facility practice expense + 0.10 malpractice RVUs, all four figures read in the CMS file on the line for CPT 93312 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 93312",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 105.21,
    "facility_setting_total_rvu": 3.15,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 3.15 facility total RVUs on the modifier 26 line x $33.4009 = $105.21 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-tee",
    "status": "PASS",
    "value_usd": 239.48,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 105.21,
      "evidence": "3.15 facility total RVUs on the modifier 26 line for 93312 x $33.4009 = $105.21"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 93312",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "7.17 total non-facility RVUs x $33.4009 = $239.48",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-stress-echo",
   "label": "Stress echocardiogram",
   "plain_language_synonyms": [
    "stress echo",
    "echo stress test",
    "exercise echocardiogram",
    "stress test with heart ultrasound",
    "dobutamine stress echo",
    "echocardiogram during exercise"
   ],
   "value_usd": 185.37,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A transthoracic echocardiogram performed during rest and stress. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 5.55 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.42 work + 4.06 non-facility practice expense + 0.07 malpractice RVUs, all four figures read in the CMS file on the line for CPT 93350 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 93350",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 67.47,
    "facility_setting_total_rvu": 2.02,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 2.02 facility total RVUs on the modifier 26 line x $33.4009 = $67.47 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-stress-echo",
    "status": "PASS",
    "value_usd": 185.37,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 67.47,
      "evidence": "2.02 facility total RVUs on the modifier 26 line for 93350 x $33.4009 = $67.47"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 93350",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "5.55 total non-facility RVUs x $33.4009 = $185.37",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-arterial-studies",
   "label": "Arm or leg artery study, three or more levels",
   "plain_language_synonyms": [
    "arterial doppler of my legs",
    "abi with segmental pressures",
    "peripheral arterial study",
    "leg artery ultrasound study",
    "circulation study of my legs",
    "arterial studies upper or lower extremity"
   ],
   "value_usd": 133.6,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A complete bilateral non-invasive study of arm or leg arteries at three or more levels. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 4.00 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.44 work + 3.47 non-facility practice expense + 0.09 malpractice RVUs, all four figures read in the CMS file on the line for CPT 93923 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 93923",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 21.38,
    "facility_setting_total_rvu": 0.64,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 0.64 facility total RVUs on the modifier 26 line x $33.4009 = $21.38 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-test-arterial-studies",
    "status": "PASS",
    "value_usd": 133.6,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 21.38,
      "evidence": "0.64 facility total RVUs on the modifier 26 line for 93923 x $33.4009 = $21.38"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 93923",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "4.00 total non-facility RVUs x $33.4009 = $133.60",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-eeg-awake-drowsy",
   "label": "Brain wave test (EEG), awake and drowsy",
   "plain_language_synonyms": [
    "eeg awake and drowsy",
    "routine eeg awake",
    "brain wave recording awake",
    "eeg without sleep",
    "awake eeg recording",
    "standard eeg while awake"
   ],
   "value_usd": 413.5,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An electroencephalogram recorded while awake and drowsy, the routine outpatient EEG. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 12.38 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.05 work + 11.23 non-facility practice expense + 0.10 malpractice RVUs, all four figures read in the CMS file on the line for CPT 95816 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 95816",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 56.45,
    "facility_setting_total_rvu": 1.69,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.69 facility total RVUs on the modifier 26 line x $33.4009 = $56.45 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-test-eeg-awake-drowsy",
    "status": "PASS",
    "value_usd": 413.5,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 56.45,
      "evidence": "1.69 facility total RVUs on the modifier 26 line for 95816 x $33.4009 = $56.45"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 95816",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "12.38 total non-facility RVUs x $33.4009 = $413.50",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-ncs-1-2",
   "label": "Nerve conduction test, 1 to 2 nerves (the shock part of an EMG/NCS appointment)",
   "plain_language_synonyms": [
    "nerve conduction study covering one or two nerves",
    "ncs with 1 to 2 studies",
    "electrodiagnostic testing of a couple of nerves",
    "short conduction study with two studies",
    "velocity testing of one or two nerves",
    "conduction testing 1-2 studies"
   ],
   "value_usd": 94.19,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A nerve conduction study covering one to two nerve studies. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 2.82 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.98 work + 1.79 non-facility practice expense + 0.05 malpractice RVUs, all four figures read in the CMS file on the line for CPT 95907 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Nerve conduction studies are almost always done in the same appointment as the needle EMG, and a person who had one usually had both. Each is billed separately, so one appointment can produce several lines. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 95907",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 53.44,
    "facility_setting_total_rvu": 1.6,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.60 facility total RVUs on the modifier 26 line x $33.4009 = $53.44 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-test-ncs-1-2",
    "status": "PASS",
    "value_usd": 94.19,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 53.44,
      "evidence": "1.60 facility total RVUs on the modifier 26 line for 95907 x $33.4009 = $53.44"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 95907",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "2.82 total non-facility RVUs x $33.4009 = $94.19",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-ncs-3-4",
   "label": "Nerve conduction test, 3 to 4 nerves (the shock part of an EMG/NCS appointment)",
   "plain_language_synonyms": [
    "nerve conduction study covering three or four nerves",
    "ncs with 3 to 4 studies",
    "electrodiagnostic testing of three or four nerves",
    "conduction study with four studies",
    "velocity testing of three or four nerves",
    "conduction testing 3-4 studies"
   ],
   "value_usd": 118.24,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A nerve conduction study covering three to four nerve studies. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.54 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.22 work + 2.26 non-facility practice expense + 0.06 malpractice RVUs, all four figures read in the CMS file on the line for CPT 95908 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Nerve conduction studies are almost always done in the same appointment as the needle EMG, and a person who had one usually had both. Each is billed separately, so one appointment can produce several lines. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 95908",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 67.14,
    "facility_setting_total_rvu": 2.01,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 2.01 facility total RVUs on the modifier 26 line x $33.4009 = $67.14 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-test-ncs-3-4",
    "status": "PASS",
    "value_usd": 118.24,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 67.14,
      "evidence": "2.01 facility total RVUs on the modifier 26 line for 95908 x $33.4009 = $67.14"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 95908",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.54 total non-facility RVUs x $33.4009 = $118.24",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-ncs-5-6",
   "label": "Nerve conduction test, 5 to 6 nerves (the shock part of an EMG/NCS appointment)",
   "plain_language_synonyms": [
    "nerve conduction study covering five or six nerves",
    "ncs with 5 to 6 studies",
    "electrodiagnostic testing of five or six nerves",
    "conduction study with six studies",
    "velocity testing of five or six nerves",
    "conduction testing 5-6 studies"
   ],
   "value_usd": 141.95,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A nerve conduction study covering five to six nerve studies. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 4.25 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.46 work + 2.72 non-facility practice expense + 0.07 malpractice RVUs, all four figures read in the CMS file on the line for CPT 95909 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Nerve conduction studies are almost always done in the same appointment as the needle EMG, and a person who had one usually had both. Each is billed separately, so one appointment can produce several lines. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 95909",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 80.16,
    "facility_setting_total_rvu": 2.4,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 2.40 facility total RVUs on the modifier 26 line x $33.4009 = $80.16 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-test-ncs-5-6",
    "status": "PASS",
    "value_usd": 141.95,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 80.16,
      "evidence": "2.40 facility total RVUs on the modifier 26 line for 95909 x $33.4009 = $80.16"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 95909",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "4.25 total non-facility RVUs x $33.4009 = $141.95",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-ncs-7-8",
   "label": "Nerve conduction test, 7 to 8 nerves (the shock part of an EMG/NCS appointment)",
   "plain_language_synonyms": [
    "nerve conduction study covering seven or eight nerves",
    "ncs with 7 to 8 studies",
    "electrodiagnostic testing of seven or eight nerves",
    "conduction study with eight studies",
    "velocity testing of seven or eight nerves",
    "conduction testing 7-8 studies"
   ],
   "value_usd": 184.71,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A nerve conduction study covering seven to eight nerve studies. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 5.53 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.95 work + 3.50 non-facility practice expense + 0.08 malpractice RVUs, all four figures read in the CMS file on the line for CPT 95910 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Nerve conduction studies are almost always done in the same appointment as the needle EMG, and a person who had one usually had both. Each is billed separately, so one appointment can produce several lines. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 95910",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 106.21,
    "facility_setting_total_rvu": 3.18,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 3.18 facility total RVUs on the modifier 26 line x $33.4009 = $106.21 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-test-ncs-7-8",
    "status": "PASS",
    "value_usd": 184.71,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 106.21,
      "evidence": "3.18 facility total RVUs on the modifier 26 line for 95910 x $33.4009 = $106.21"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 95910",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "5.53 total non-facility RVUs x $33.4009 = $184.71",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-ncs-9-10",
   "label": "Nerve conduction test, 9 to 10 nerves (the shock part of an EMG/NCS appointment)",
   "plain_language_synonyms": [
    "nerve conduction study covering nine or ten nerves",
    "ncs with 9 to 10 studies",
    "electrodiagnostic testing of nine or ten nerves",
    "conduction study with ten studies",
    "velocity testing of nine or ten nerves",
    "conduction testing 9-10 studies"
   ],
   "value_usd": 220.11,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A nerve conduction study covering nine to ten nerve studies. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 6.59 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 2.44 work + 4.05 non-facility practice expense + 0.10 malpractice RVUs, all four figures read in the CMS file on the line for CPT 95911 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Nerve conduction studies are almost always done in the same appointment as the needle EMG, and a person who had one usually had both. Each is billed separately, so one appointment can produce several lines. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 95911",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 132.6,
    "facility_setting_total_rvu": 3.97,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 3.97 facility total RVUs on the modifier 26 line x $33.4009 = $132.60 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-test-ncs-9-10",
    "status": "PASS",
    "value_usd": 220.11,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 132.6,
      "evidence": "3.97 facility total RVUs on the modifier 26 line for 95911 x $33.4009 = $132.60"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 95911",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "6.59 total non-facility RVUs x $33.4009 = $220.11",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-ncs-11-12",
   "label": "Nerve conduction test, 11 to 12 nerves (the shock part of an EMG/NCS appointment)",
   "plain_language_synonyms": [
    "nerve conduction study covering eleven or twelve nerves",
    "ncs with 11 to 12 studies",
    "electrodiagnostic testing of eleven or twelve nerves",
    "conduction study with twelve studies",
    "velocity testing of eleven or twelve nerves",
    "conduction testing 11-12 studies"
   ],
   "value_usd": 254.85,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A nerve conduction study covering eleven to twelve nerve studies. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 7.63 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 2.93 work + 4.56 non-facility practice expense + 0.14 malpractice RVUs, all four figures read in the CMS file on the line for CPT 95912 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Nerve conduction studies are almost always done in the same appointment as the needle EMG, and a person who had one usually had both. Each is billed separately, so one appointment can produce several lines. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 95912",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 158.32,
    "facility_setting_total_rvu": 4.74,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 4.74 facility total RVUs on the modifier 26 line x $33.4009 = $158.32 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-test-ncs-11-12",
    "status": "PASS",
    "value_usd": 254.85,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 158.32,
      "evidence": "4.74 facility total RVUs on the modifier 26 line for 95912 x $33.4009 = $158.32"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 95912",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "7.63 total non-facility RVUs x $33.4009 = $254.85",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-ncs-13plus",
   "label": "Nerve conduction test, 13 or more nerves (the shock part of an EMG/NCS appointment)",
   "plain_language_synonyms": [
    "nerve conduction study covering thirteen or more nerves",
    "ncs with 13 or more studies",
    "extensive electrodiagnostic conduction testing",
    "a full survey of thirteen or more nerves",
    "velocity testing of many separate nerves",
    "conduction testing 13 or more studies"
   ],
   "value_usd": 299.94,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A nerve conduction study covering thirteen or more nerve studies. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 8.98 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 3.47 work + 5.35 non-facility practice expense + 0.16 malpractice RVUs, all four figures read in the CMS file on the line for CPT 95913 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Nerve conduction studies are almost always done in the same appointment as the needle EMG, and a person who had one usually had both. Each is billed separately, so one appointment can produce several lines. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 95913",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 187.71,
    "facility_setting_total_rvu": 5.62,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 5.62 facility total RVUs on the modifier 26 line x $33.4009 = $187.71 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-test-ncs-13plus",
    "status": "PASS",
    "value_usd": 299.94,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 187.71,
      "evidence": "5.62 facility total RVUs on the modifier 26 line for 95913 x $33.4009 = $187.71"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 95913",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "8.98 total non-facility RVUs x $33.4009 = $299.94",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-emg-limited",
   "label": "Needle EMG of one limb done with a nerve conduction test, limited",
   "plain_language_synonyms": [
    "limited needle emg done with a conduction study",
    "emg limited study of one limb",
    "needle exam limited to one extremity",
    "emg add on limited study",
    "limited electromyography of one limb",
    "partial needle emg of one arm or leg"
   ],
   "value_usd": 64.46,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A limited needle electromyography study of one limb, performed in the same session as a nerve conduction study. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.93 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.34 work + 1.58 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 95885 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. Nerve conduction studies are almost always done in the same appointment as the needle EMG, and a person who had one usually had both. Each is billed separately, so one appointment can produce several lines. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 95885",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 18.37,
    "facility_setting_total_rvu": 0.55,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 0.55 facility total RVUs on the modifier 26 line x $33.4009 = $18.37 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-test-emg-limited",
    "status": "PASS",
    "value_usd": 64.46,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 18.37,
      "evidence": "0.55 facility total RVUs on the modifier 26 line for 95885 x $33.4009 = $18.37"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 95885",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.93 total non-facility RVUs x $33.4009 = $64.46",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-lumbar-puncture",
   "label": "Spinal tap (lumbar puncture), diagnostic",
   "plain_language_synonyms": [
    "spinal tap",
    "lumbar puncture",
    "they took spinal fluid",
    "diagnostic lp",
    "needle in my spine for fluid",
    "csf collection by lumbar puncture"
   ],
   "value_usd": 165,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A diagnostic lumbar puncture to collect spinal fluid. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 4.94 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.19 work + 3.46 non-facility practice expense + 0.29 malpractice RVUs, all four figures read in the CMS file on the line for CPT 62270 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 62270",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 58.79,
    "facility_setting_total_rvu": 1.76,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 1.76 facility total RVUs x $33.4009 = $58.79. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-lumbar-puncture",
    "status": "PASS",
    "value_usd": 165,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 58.79,
      "evidence": "1.76 facility total RVUs on the unmodified line for 62270 x $33.4009 = $58.79"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 62270",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "4.94 total non-facility RVUs x $33.4009 = $165.00",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-epley",
   "label": "Epley manoeuvre for vertigo",
   "plain_language_synonyms": [
    "epley manoeuvre",
    "canalith repositioning",
    "they moved my head to fix the vertigo",
    "bppv repositioning treatment",
    "epley maneuver for dizziness",
    "vertigo repositioning treatment"
   ],
   "value_usd": 40.75,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "Canalith repositioning, the Epley or similar manoeuvre used to treat positional vertigo. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.22 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.73 work + 0.47 non-facility practice expense + 0.02 malpractice RVUs, all four figures read in the CMS file on the line for CPT 95992 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 95992",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 29.73,
    "facility_setting_total_rvu": 0.89,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 0.89 facility total RVUs x $33.4009 = $29.73. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-epley",
    "status": "PASS",
    "value_usd": 40.75,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 29.73,
      "evidence": "0.89 facility total RVUs on the unmodified line for 95992 x $33.4009 = $29.73"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 95992",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.22 total non-facility RVUs x $33.4009 = $40.75",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-home-sleep-full",
   "label": "Home sleep apnea test with breathing effort and oxygen",
   "plain_language_synonyms": [
    "home sleep apnea test with effort",
    "at home sleep test with oxygen sensor",
    "unattended sleep study with effort",
    "home sleep test full",
    "portable sleep apnea test with oximetry",
    "sleep test i did at home with a belt"
   ],
   "value_usd": 141.29,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An unattended sleep study done at home, measuring sleep time, breathing effort and oxygen saturation. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 4.23 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.83 work + 3.34 non-facility practice expense + 0.06 malpractice RVUs, all four figures read in the CMS file on the line for CPT 95800 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 95800",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 38.75,
    "facility_setting_total_rvu": 1.16,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.16 facility total RVUs on the modifier 26 line x $33.4009 = $38.75 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-test-home-sleep-full",
    "status": "PASS",
    "value_usd": 141.29,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 38.75,
      "evidence": "1.16 facility total RVUs on the modifier 26 line for 95800 x $33.4009 = $38.75"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 95800",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "4.23 total non-facility RVUs x $33.4009 = $141.29",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-home-sleep-basic",
   "label": "Home sleep apnea test, unattended",
   "plain_language_synonyms": [
    "home sleep apnea test",
    "at home sleep study",
    "portable sleep test",
    "unattended sleep study at home",
    "sleep apnea test i took home",
    "home sleep test basic"
   ],
   "value_usd": 103.21,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An unattended home sleep study recording airflow, breathing effort and oxygen saturation. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.09 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.91 work + 2.12 non-facility practice expense + 0.06 malpractice RVUs, all four figures read in the CMS file on the line for CPT 95806 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 95806",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 44.76,
    "facility_setting_total_rvu": 1.34,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.34 facility total RVUs on the modifier 26 line x $33.4009 = $44.76 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-test-home-sleep-basic",
    "status": "PASS",
    "value_usd": 103.21,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 44.76,
      "evidence": "1.34 facility total RVUs on the modifier 26 line for 95806 x $33.4009 = $44.76"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 95806",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.09 total non-facility RVUs x $33.4009 = $103.21",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-sleep-cpap",
   "label": "Overnight sleep study with CPAP titration",
   "plain_language_synonyms": [
    "cpap titration study",
    "sleep study with cpap fitting",
    "titration night in the sleep lab",
    "second sleep study with a mask",
    "polysomnography with cpap",
    "sleep lab night to set my cpap"
   ],
   "value_usd": 707.77,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An attended overnight polysomnogram with initiation and titration of positive airway pressure. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 21.19 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 2.54 work + 18.37 non-facility practice expense + 0.28 malpractice RVUs, all four figures read in the CMS file on the line for CPT 95811 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 95811",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 123.92,
    "facility_setting_total_rvu": 3.71,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 3.71 facility total RVUs on the modifier 26 line x $33.4009 = $123.92 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-test-sleep-cpap",
    "status": "PASS",
    "value_usd": 707.77,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 123.92,
      "evidence": "3.71 facility total RVUs on the modifier 26 line for 95811 x $33.4009 = $123.92"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 95811",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "21.19 total non-facility RVUs x $33.4009 = $707.77",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-colonoscopy-biopsy",
   "label": "Colonoscopy with biopsy, physician’s fee",
   "plain_language_synonyms": [
    "colonoscopy with biopsy",
    "colonoscopy where they took samples",
    "colon scope with biopsies",
    "bowel camera with biopsy",
    "colonoscopy and biopsies taken",
    "they biopsied during my colonoscopy"
   ],
   "value_usd": 479.97,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A colonoscopy with one or more biopsies taken, the physician’s fee. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 14.37 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 3.47 work + 10.48 non-facility practice expense + 0.42 malpractice RVUs, all four figures read in the CMS file on the line for CPT 45380 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the physician’s fee. A hospital or ambulatory surgery centre bills its own facility fee, and anaesthesia is billed separately again. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 45380",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 177.69,
    "facility_setting_total_rvu": 5.32,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 5.32 facility total RVUs x $33.4009 = $177.69. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-colonoscopy-biopsy",
    "status": "PASS",
    "value_usd": 479.97,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 177.69,
      "evidence": "5.32 facility total RVUs on the unmodified line for 45380 x $33.4009 = $177.69"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 45380",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "14.37 total non-facility RVUs x $33.4009 = $479.97",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-colonoscopy-polyp",
   "label": "Colonoscopy with polyp removal, physician’s fee",
   "plain_language_synonyms": [
    "colonoscopy with polyp removal",
    "they removed polyps during my colonoscopy",
    "colonoscopy with snare polypectomy",
    "polyp taken out during colonoscopy",
    "colon scope with polypectomy",
    "colonoscopy and polyps removed"
   ],
   "value_usd": 500.01,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A colonoscopy with removal of a lesion by snare technique, the physician’s fee. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 14.97 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 4.46 work + 10.00 non-facility practice expense + 0.51 malpractice RVUs, all four figures read in the CMS file on the line for CPT 45385 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the physician’s fee. A hospital or ambulatory surgery centre bills its own facility fee, and anaesthesia is billed separately again. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 45385",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 223.45,
    "facility_setting_total_rvu": 6.69,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 6.69 facility total RVUs x $33.4009 = $223.45. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-colonoscopy-polyp",
    "status": "PASS",
    "value_usd": 500.01,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 223.45,
      "evidence": "6.69 facility total RVUs on the unmodified line for 45385 x $33.4009 = $223.45"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 45385",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "14.97 total non-facility RVUs x $33.4009 = $500.01",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-sigmoidoscopy",
   "label": "Flexible sigmoidoscopy, diagnostic",
   "plain_language_synonyms": [
    "flexible sigmoidoscopy",
    "sigmoidoscopy",
    "short colon scope",
    "scope of my lower bowel",
    "flex sig procedure",
    "partial colonoscopy sigmoidoscopy"
   ],
   "value_usd": 215.1,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A diagnostic flexible sigmoidoscopy, the physician’s fee. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 6.44 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.82 work + 5.50 non-facility practice expense + 0.12 malpractice RVUs, all four figures read in the CMS file on the line for CPT 45330 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 45330",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 53.78,
    "facility_setting_total_rvu": 1.61,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 1.61 facility total RVUs x $33.4009 = $53.78. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-sigmoidoscopy",
    "status": "PASS",
    "value_usd": 215.1,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 53.78,
      "evidence": "1.61 facility total RVUs on the unmodified line for 45330 x $33.4009 = $53.78"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 45330",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "6.44 total non-facility RVUs x $33.4009 = $215.10",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-egd-dx",
   "label": "Upper endoscopy without biopsy, physician’s fee",
   "plain_language_synonyms": [
    "upper endoscopy without biopsy",
    "diagnostic egd",
    "scope down my throat no samples",
    "esophagogastroduodenoscopy diagnostic",
    "upper gi scope without biopsy",
    "egd brushing or washing only"
   ],
   "value_usd": 322.65,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A diagnostic upper endoscopy with or without collection of specimens by brushing or washing, the physician’s fee. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 9.66 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 2.04 work + 7.38 non-facility practice expense + 0.24 malpractice RVUs, all four figures read in the CMS file on the line for CPT 43235 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the physician’s fee. A hospital or ambulatory surgery centre bills its own facility fee, and anaesthesia is billed separately again. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 43235",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 110.56,
    "facility_setting_total_rvu": 3.31,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 3.31 facility total RVUs x $33.4009 = $110.56. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-egd-dx",
    "status": "PASS",
    "value_usd": 322.65,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 110.56,
      "evidence": "3.31 facility total RVUs on the unmodified line for 43235 x $33.4009 = $110.56"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 43235",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "9.66 total non-facility RVUs x $33.4009 = $322.65",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-capsule-endoscopy",
   "label": "Camera pill study of the small bowel",
   "plain_language_synonyms": [
    "capsule endoscopy",
    "camera pill i swallowed",
    "pillcam study",
    "small bowel capsule study",
    "swallowed a camera capsule",
    "video capsule endoscopy"
   ],
   "value_usd": 802.29,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A capsule endoscopy imaging the small bowel from the oesophagus through the ileum. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 24.02 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 2.18 work + 21.75 non-facility practice expense + 0.09 malpractice RVUs, all four figures read in the CMS file on the line for CPT 91110 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 91110",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 117.91,
    "facility_setting_total_rvu": 3.53,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 3.53 facility total RVUs on the modifier 26 line x $33.4009 = $117.91 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-test-capsule-endoscopy",
    "status": "PASS",
    "value_usd": 802.29,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 117.91,
      "evidence": "3.53 facility total RVUs on the modifier 26 line for 91110 x $33.4009 = $117.91"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 91110",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "24.02 total non-facility RVUs x $33.4009 = $802.29",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-esophageal-ph",
   "label": "Acid reflux probe study (pH study)",
   "plain_language_synonyms": [
    "esophageal ph study",
    "reflux probe test",
    "acid reflux monitoring study",
    "ph probe in my esophagus",
    "gastroesophageal reflux test",
    "24 hour reflux study"
   ],
   "value_usd": 202.41,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A gastroesophageal reflux test with a pH electrode placed in the oesophagus. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 6.06 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.95 work + 5.03 non-facility practice expense + 0.08 malpractice RVUs, all four figures read in the CMS file on the line for CPT 91034 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 91034",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 50.44,
    "facility_setting_total_rvu": 1.51,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.51 facility total RVUs on the modifier 26 line x $33.4009 = $50.44 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-test-esophageal-ph",
    "status": "PASS",
    "value_usd": 202.41,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 50.44,
      "evidence": "1.51 facility total RVUs on the modifier 26 line for 91034 x $33.4009 = $50.44"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 91034",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "6.06 total non-facility RVUs x $33.4009 = $202.41",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-img-upper-gi-series",
   "label": "Barium swallow / upper GI series",
   "plain_language_synonyms": [
    "upper gi series",
    "barium swallow study",
    "barium x ray of my stomach",
    "upper gi with air contrast",
    "drank barium for an x ray",
    "fluoroscopy of my upper gi tract"
   ],
   "value_usd": 134.61,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A radiological examination of the upper gastrointestinal tract with double contrast. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 4.03 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.88 work + 3.09 non-facility practice expense + 0.06 malpractice RVUs, all four figures read in the CMS file on the line for CPT 74246 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 74246",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 41.75,
    "facility_setting_total_rvu": 1.25,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.25 facility total RVUs on the modifier 26 line x $33.4009 = $41.75 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-img-upper-gi-series",
    "status": "PASS",
    "value_usd": 134.61,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 41.75,
      "evidence": "1.25 facility total RVUs on the modifier 26 line for 74246 x $33.4009 = $41.75"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 74246",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "4.03 total non-facility RVUs x $33.4009 = $134.61",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-gastric-emptying",
   "label": "Gastric emptying study",
   "plain_language_synonyms": [
    "gastric emptying study",
    "stomach emptying test",
    "ate radioactive eggs for a scan",
    "gastroparesis test",
    "nuclear stomach emptying scan",
    "gastric emptying scintigraphy"
   ],
   "value_usd": 289.92,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A nuclear medicine gastric emptying imaging study. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 8.68 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.77 work + 7.82 non-facility practice expense + 0.09 malpractice RVUs, all four figures read in the CMS file on the line for CPT 78264 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 78264",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 35.74,
    "facility_setting_total_rvu": 1.07,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.07 facility total RVUs on the modifier 26 line x $33.4009 = $35.74 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-test-gastric-emptying",
    "status": "PASS",
    "value_usd": 289.92,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 35.74,
      "evidence": "1.07 facility total RVUs on the modifier 26 line for 78264 x $33.4009 = $35.74"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 78264",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "8.68 total non-facility RVUs x $33.4009 = $289.92",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-breath-hydrogen",
   "label": "Breath test for lactose intolerance or bacterial overgrowth",
   "plain_language_synonyms": [
    "hydrogen breath test",
    "lactose intolerance breath test",
    "sibo breath test",
    "methane breath test",
    "breath test for bacterial overgrowth",
    "breath sample test for lactose"
   ],
   "value_usd": 64.46,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A breath hydrogen or methane test, used for lactose intolerance and small bowel bacterial overgrowth. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.93 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.20 work + 1.71 non-facility practice expense + 0.02 malpractice RVUs, all four figures read in the CMS file on the line for CPT 91065 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 91065",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 9.69,
    "facility_setting_total_rvu": 0.29,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 0.29 facility total RVUs on the modifier 26 line x $33.4009 = $9.69 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-test-breath-hydrogen",
    "status": "PASS",
    "value_usd": 64.46,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 9.69,
      "evidence": "0.29 facility total RVUs on the modifier 26 line for 91065 x $33.4009 = $9.69"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 91065",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.93 total non-facility RVUs x $33.4009 = $64.46",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-g0121-screening-colonoscopy",
   "label": "Screening colonoscopy, average risk",
   "plain_language_synonyms": [
    "screening colonoscopy",
    "routine colonoscopy screening",
    "colon cancer screening colonoscopy",
    "my first screening colonoscopy at 45",
    "preventive colonoscopy",
    "colonoscopy for screening not symptoms"
   ],
   "value_usd": 378.43,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A colorectal cancer screening colonoscopy in a person not at high risk, the physician’s fee. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 11.33 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 3.18 work + 7.73 non-facility practice expense + 0.42 malpractice RVUs, all four figures read in the CMS file on the line for HCPCS G0121 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the physician’s fee. A hospital or ambulatory surgery centre bills its own facility fee, and anaesthesia is billed separately again. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "HCPCS G0121",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 165,
    "facility_setting_total_rvu": 4.94,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 4.94 facility total RVUs x $33.4009 = $165.00. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-g0121-screening-colonoscopy",
    "status": "PASS",
    "value_usd": 378.43,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 165,
      "evidence": "4.94 facility total RVUs on the unmodified line for G0121 x $33.4009 = $165.00"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "HCPCS G0121",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "11.33 total non-facility RVUs x $33.4009 = $378.43",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-spirometry-bronchodilator",
   "label": "Breathing test before and after an inhaler",
   "plain_language_synonyms": [
    "spirometry with bronchodilator",
    "breathing test with an inhaler",
    "pre and post bronchodilator spirometry",
    "lung test before and after medication",
    "reversibility breathing test",
    "evaluation of wheezing with spirometry"
   ],
   "value_usd": 43.42,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "Spirometry repeated after a bronchodilator, the test used to look for reversible airway obstruction. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.30 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.21 work + 1.07 non-facility practice expense + 0.02 malpractice RVUs, all four figures read in the CMS file on the line for CPT 94060 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 94060",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 10.35,
    "facility_setting_total_rvu": 0.31,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 0.31 facility total RVUs on the modifier 26 line x $33.4009 = $10.35 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-test-spirometry-bronchodilator",
    "status": "PASS",
    "value_usd": 43.42,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 10.35,
      "evidence": "0.31 facility total RVUs on the modifier 26 line for 94060 x $33.4009 = $10.35"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 94060",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.30 total non-facility RVUs x $33.4009 = $43.42",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-treat-nebulizer",
   "label": "Nebulizer breathing treatment",
   "plain_language_synonyms": [
    "nebulizer treatment",
    "breathing treatment in the office",
    "nebuliser in the clinic",
    "inhalation treatment for wheezing",
    "albuterol nebulizer treatment",
    "they gave me a breathing treatment"
   ],
   "value_usd": 8.68,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An inhalation treatment delivered by nebulizer for airway obstruction. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.26 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.00 work + 0.25 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 94640 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 94640",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-treat-nebulizer",
    "status": "PASS",
    "value_usd": 8.68,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 94640",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.26 total non-facility RVUs x $33.4009 = $8.68",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-allergy-intradermal-per-test",
   "label": "Intradermal allergy test, price per individual allergen",
   "plain_language_synonyms": [
    "intradermal allergy test",
    "allergy testing with injections under the skin",
    "intracutaneous allergy test",
    "deeper allergy skin test",
    "allergy shots test per allergen",
    "id allergy testing per allergen"
   ],
   "value_usd": 7.68,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "One intradermal allergy test with an allergenic extract. The price is per individual allergen tested, so a panel of thirty is thirty of these. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.23 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.01 work + 0.21 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 95024 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 95024",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 1,
    "facility_setting_total_rvu": 0.03,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 0.03 facility total RVUs x $33.4009 = $1.00. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-test-allergy-intradermal-per-test",
    "status": "PASS",
    "value_usd": 7.68,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 1,
      "evidence": "0.03 facility total RVUs on the unmodified line for 95024 x $33.4009 = $1.00"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 95024",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.23 total non-facility RVUs x $33.4009 = $7.68",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-patch-testing-per-test",
   "label": "Allergy patch test, price per individual patch",
   "plain_language_synonyms": [
    "patch testing",
    "allergy patches on my back",
    "contact dermatitis patch test",
    "patch test per allergen",
    "skin patch allergy testing",
    "they taped allergens to my back"
   ],
   "value_usd": 5.01,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "One allergy patch or application test. The price is per individual patch, so a standard series is many of these. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.15 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.00 work + 0.14 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 95044 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 95044",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-test-patch-testing-per-test",
    "status": "PASS",
    "value_usd": 5.01,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 95044",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.15 total non-facility RVUs x $33.4009 = $5.01",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-treat-allergy-shot",
   "label": "Allergy immunotherapy, price per dose prepared",
   "plain_language_synonyms": [
    "allergy shots",
    "immunotherapy allergy injection",
    "allergy serum dose",
    "weekly allergy shot",
    "antigen therapy dose",
    "allergy desensitisation injection"
   ],
   "value_usd": 17.37,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The preparation of a single dose of allergenic extract for immunotherapy. A course of allergy shots is many of these. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.52 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.06 work + 0.45 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 95165 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 95165",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 2.67,
    "facility_setting_total_rvu": 0.08,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 0.08 facility total RVUs x $33.4009 = $2.67. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-treat-allergy-shot",
    "status": "PASS",
    "value_usd": 17.37,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 2.67,
      "evidence": "0.08 facility total RVUs on the unmodified line for 95165 x $33.4009 = $2.67"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 95165",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.52 total non-facility RVUs x $33.4009 = $17.37",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-injection-im",
   "label": "Shot in the arm or hip given at a visit",
   "plain_language_synonyms": [
    "intramuscular injection at the office",
    "they gave me a shot",
    "im injection administration",
    "subcutaneous injection given in clinic",
    "injection administration fee",
    "shot in my hip at the clinic"
   ],
   "value_usd": 15.36,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The fee for administering a therapeutic, prophylactic or diagnostic injection into muscle or under the skin. The drug itself is billed separately. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.46 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.17 work + 0.28 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 96372 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the fee for GIVING the injection. The medicine is billed separately, and for an expensive drug the medicine is usually the larger figure. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 96372",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-proc-injection-im",
    "status": "PASS",
    "value_usd": 15.36,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 96372",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.46 total non-facility RVUs x $33.4009 = $15.36",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-iv-infusion-first-hour",
   "label": "IV infusion at a clinic, first hour",
   "plain_language_synonyms": [
    "iv infusion first hour",
    "infusion appointment first hour",
    "iv drip at the infusion centre",
    "intravenous infusion administration",
    "they ran an iv for an hour",
    "infusion therapy first hour"
   ],
   "value_usd": 67.14,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The fee for administering an intravenous infusion, up to the first hour. The drug itself is billed separately. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 2.01 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.21 work + 1.76 non-facility practice expense + 0.04 malpractice RVUs, all four figures read in the CMS file on the line for CPT 96365 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the fee for GIVING the infusion. The medicine is billed separately, and for a biologic drug the medicine is usually many times this figure. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 96365",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-proc-iv-infusion-first-hour",
    "status": "PASS",
    "value_usd": 67.14,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 96365",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "2.01 total non-facility RVUs x $33.4009 = $67.14",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-iv-infusion-extra-hour",
   "label": "IV infusion at a clinic, each extra hour",
   "plain_language_synonyms": [
    "iv infusion additional hour",
    "each extra hour of my infusion",
    "infusion add on hour",
    "sequential infusion hour",
    "extra hour on the iv drip",
    "additional infusion time"
   ],
   "value_usd": 21.38,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The fee for each additional hour of an intravenous infusion beyond the first. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.64 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.18 work + 0.45 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 96366 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is an add-on to the first hour, not a separate visit. The medicine is billed separately. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 96366",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-proc-iv-infusion-extra-hour",
    "status": "PASS",
    "value_usd": 21.38,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 96366",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.64 total non-facility RVUs x $33.4009 = $21.38",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-iv-push",
   "label": "IV push of a drug at a clinic",
   "plain_language_synonyms": [
    "iv push",
    "they pushed a drug through my iv",
    "intravenous push administration",
    "quick iv medication push",
    "iv bolus administration",
    "single iv push of medicine"
   ],
   "value_usd": 37.74,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The fee for administering a drug by intravenous push. The drug itself is billed separately. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.13 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.18 work + 0.93 non-facility practice expense + 0.02 malpractice RVUs, all four figures read in the CMS file on the line for CPT 96374 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the fee for GIVING the drug. The medicine is billed separately. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 96374",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-proc-iv-push",
    "status": "PASS",
    "value_usd": 37.74,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 96374",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.13 total non-facility RVUs x $33.4009 = $37.74",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-joint-injection-small",
   "label": "Injection into a small or middle-sized joint",
   "plain_language_synonyms": [
    "injection in a small joint",
    "shot in my wrist joint",
    "aspiration of a small joint",
    "injection into my ankle joint",
    "intermediate joint injection",
    "steroid shot in a small joint"
   ],
   "value_usd": 57.12,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An injection into, or fluid drawn from, an intermediate joint or bursa, without ultrasound guidance. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.71 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.66 work + 0.97 non-facility practice expense + 0.08 malpractice RVUs, all four figures read in the CMS file on the line for CPT 20605 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 20605",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 32.06,
    "facility_setting_total_rvu": 0.96,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 0.96 facility total RVUs x $33.4009 = $32.06. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-joint-injection-small",
    "status": "PASS",
    "value_usd": 57.12,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 32.06,
      "evidence": "0.96 facility total RVUs on the unmodified line for 20605 x $33.4009 = $32.06"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 20605",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.71 total non-facility RVUs x $33.4009 = $57.12",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-joint-injection-us",
   "label": "Joint injection with ultrasound guidance",
   "plain_language_synonyms": [
    "joint injection with ultrasound guidance",
    "ultrasound guided joint injection",
    "they used ultrasound for my joint shot",
    "image guided joint aspiration",
    "guided injection into a large joint",
    "joint shot under ultrasound"
   ],
   "value_usd": 104.21,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An injection into, or fluid drawn from, a major joint or bursa, with ultrasound guidance and a permanent recording. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.12 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.07 work + 1.91 non-facility practice expense + 0.14 malpractice RVUs, all four figures read in the CMS file on the line for CPT 20611 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 20611",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 50.1,
    "facility_setting_total_rvu": 1.5,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 1.50 facility total RVUs x $33.4009 = $50.10. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-joint-injection-us",
    "status": "PASS",
    "value_usd": 104.21,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 50.1,
      "evidence": "1.50 facility total RVUs on the unmodified line for 20611 x $33.4009 = $50.10"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 20611",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.12 total non-facility RVUs x $33.4009 = $104.21",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-tendon-injection",
   "label": "Injection into a tendon or plantar fascia",
   "plain_language_synonyms": [
    "tendon sheath injection",
    "plantar fascia injection",
    "shot in my heel for plantar fasciitis",
    "injection into a tendon",
    "ligament injection",
    "steroid shot in a tendon"
   ],
   "value_usd": 60.46,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An injection into a single tendon sheath, ligament or aponeurosis such as the plantar fascia. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.81 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.73 work + 0.99 non-facility practice expense + 0.09 malpractice RVUs, all four figures read in the CMS file on the line for CPT 20550 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 20550",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 33.4,
    "facility_setting_total_rvu": 1,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 1.00 facility total RVUs x $33.4009 = $33.40. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-tendon-injection",
    "status": "PASS",
    "value_usd": 60.46,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 33.4,
      "evidence": "1.00 facility total RVUs on the unmodified line for 20550 x $33.4009 = $33.40"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 20550",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.81 total non-facility RVUs x $33.4009 = $60.46",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-trigger-point-1-2",
   "label": "Trigger point injection, one or two muscles",
   "plain_language_synonyms": [
    "trigger point injection",
    "shots in my muscle knots",
    "trigger point shots one or two muscles",
    "muscle knot injections",
    "myofascial trigger point injection",
    "injection into tight muscles"
   ],
   "value_usd": 51.77,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "Injection of one or two trigger points in one or two muscles. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.55 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.64 work + 0.84 non-facility practice expense + 0.07 malpractice RVUs, all four figures read in the CMS file on the line for CPT 20552 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 20552",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 35.74,
    "facility_setting_total_rvu": 1.07,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 1.07 facility total RVUs x $33.4009 = $35.74. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-trigger-point-1-2",
    "status": "PASS",
    "value_usd": 51.77,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 35.74,
      "evidence": "1.07 facility total RVUs on the unmodified line for 20552 x $33.4009 = $35.74"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 20552",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.55 total non-facility RVUs x $33.4009 = $51.77",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-epidural-transforaminal",
   "label": "Steroid injection into a lower-back nerve root",
   "plain_language_synonyms": [
    "transforaminal epidural steroid injection",
    "nerve root block in my lower back",
    "selective nerve root injection lumbar",
    "epidural injection at one lumbar level",
    "tfesi injection",
    "nerve block for sciatica"
   ],
   "value_usd": 264.87,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A transforaminal epidural injection of steroid or anaesthetic at one lumbar or sacral level, with imaging guidance. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 7.93 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.85 work + 5.91 non-facility practice expense + 0.17 malpractice RVUs, all four figures read in the CMS file on the line for CPT 64483 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee. If it was done in a hospital outpatient department or a surgery centre, that facility bills its own charge on top of it, and anaesthesia is billed separately again. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 64483",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 99.53,
    "facility_setting_total_rvu": 2.98,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 2.98 facility total RVUs x $33.4009 = $99.53. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-epidural-transforaminal",
    "status": "PASS",
    "value_usd": 264.87,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 99.53,
      "evidence": "2.98 facility total RVUs on the unmodified line for 64483 x $33.4009 = $99.53"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 64483",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "7.93 total non-facility RVUs x $33.4009 = $264.87",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-epidural-interlaminar",
   "label": "Epidural steroid injection in the lower back",
   "plain_language_synonyms": [
    "epidural steroid injection",
    "lumbar epidural injection",
    "interlaminar epidural in my back",
    "epidural for back pain",
    "steroid injection in my spine",
    "caudal epidural injection"
   ],
   "value_usd": 273.22,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An interlaminar epidural or subarachnoid injection of steroid or anaesthetic in the lumbar or sacral spine, with imaging guidance. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 8.18 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.76 work + 6.25 non-facility practice expense + 0.17 malpractice RVUs, all four figures read in the CMS file on the line for CPT 62323 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee. If it was done in a hospital outpatient department or a surgery centre, that facility bills its own charge on top of it, and anaesthesia is billed separately again. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 62323",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 89.18,
    "facility_setting_total_rvu": 2.67,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 2.67 facility total RVUs x $33.4009 = $89.18. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-epidural-interlaminar",
    "status": "PASS",
    "value_usd": 273.22,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 89.18,
      "evidence": "2.67 facility total RVUs on the unmodified line for 62323 x $33.4009 = $89.18"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 62323",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "8.18 total non-facility RVUs x $33.4009 = $273.22",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-skin-biopsy-shave",
   "label": "Skin biopsy, shaved sample, one spot",
   "plain_language_synonyms": [
    "skin biopsy",
    "they shaved off a piece of skin to test it",
    "tangential skin biopsy",
    "shave biopsy of a mole",
    "dermatologist took a skin sample",
    "biopsy of a skin lesion"
   ],
   "value_usd": 95.53,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A tangential (shave) biopsy of a single skin lesion. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 2.86 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.64 work + 2.16 non-facility practice expense + 0.06 malpractice RVUs, all four figures read in the CMS file on the line for CPT 11102 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the biopsy itself. The pathologist’s examination of the sample is billed separately, usually under CPT 88305. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 11102",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 30.06,
    "facility_setting_total_rvu": 0.9,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 0.90 facility total RVUs x $33.4009 = $30.06. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-skin-biopsy-shave",
    "status": "PASS",
    "value_usd": 95.53,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 30.06,
      "evidence": "0.90 facility total RVUs on the unmodified line for 11102 x $33.4009 = $30.06"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 11102",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "2.86 total non-facility RVUs x $33.4009 = $95.53",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-skin-biopsy-punch",
   "label": "Skin biopsy, punch sample, one spot",
   "plain_language_synonyms": [
    "punch biopsy",
    "punch biopsy of my skin",
    "they punched out a piece of skin",
    "skin punch sample",
    "punch biopsy of a rash",
    "deeper skin biopsy"
   ],
   "value_usd": 121.25,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A punch biopsy of a single skin lesion. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.63 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.81 work + 2.73 non-facility practice expense + 0.09 malpractice RVUs, all four figures read in the CMS file on the line for CPT 11104 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the biopsy itself. The pathologist’s examination of the sample is billed separately, usually under CPT 88305. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 11104",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 38.08,
    "facility_setting_total_rvu": 1.14,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 1.14 facility total RVUs x $33.4009 = $38.08. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-skin-biopsy-punch",
    "status": "PASS",
    "value_usd": 121.25,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 38.08,
      "evidence": "1.14 facility total RVUs on the unmodified line for 11104 x $33.4009 = $38.08"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 11104",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.63 total non-facility RVUs x $33.4009 = $121.25",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-wart-removal",
   "label": "Freezing or burning off warts, up to 14",
   "plain_language_synonyms": [
    "wart removal",
    "they froze off my warts",
    "cryotherapy for warts",
    "destruction of benign skin lesions",
    "burning off skin tags or warts",
    "liquid nitrogen for warts"
   ],
   "value_usd": 111.22,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "Destruction of up to fourteen benign skin lesions such as warts, by freezing, burning or chemical means. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.33 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.68 work + 2.58 non-facility practice expense + 0.07 malpractice RVUs, all four figures read in the CMS file on the line for CPT 17110 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 17110",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 62.46,
    "facility_setting_total_rvu": 1.87,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 1.87 facility total RVUs x $33.4009 = $62.46. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-wart-removal",
    "status": "PASS",
    "value_usd": 111.22,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 62.46,
      "evidence": "1.87 facility total RVUs on the unmodified line for 17110 x $33.4009 = $62.46"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 17110",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.33 total non-facility RVUs x $33.4009 = $111.22",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-precancer-destruction",
   "label": "Freezing off a precancerous skin spot",
   "plain_language_synonyms": [
    "freezing a precancerous spot",
    "actinic keratosis treatment",
    "cryotherapy for a precancer",
    "destruction of a premalignant lesion",
    "they froze a sun spot",
    "liquid nitrogen for an actinic keratosis"
   ],
   "value_usd": 66.47,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "Destruction of the first premalignant skin lesion, such as an actinic keratosis. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.99 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.59 work + 1.34 non-facility practice expense + 0.06 malpractice RVUs, all four figures read in the CMS file on the line for CPT 17000 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 17000",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 47.76,
    "facility_setting_total_rvu": 1.43,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 1.43 facility total RVUs x $33.4009 = $47.76. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-precancer-destruction",
    "status": "PASS",
    "value_usd": 66.47,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 47.76,
      "evidence": "1.43 facility total RVUs on the unmodified line for 17000 x $33.4009 = $47.76"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 17000",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.99 total non-facility RVUs x $33.4009 = $66.47",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-abscess-drainage",
   "label": "Draining an abscess or boil",
   "plain_language_synonyms": [
    "abscess drainage",
    "they drained a boil",
    "incision and drainage of an abscess",
    "lanced an abscess",
    "drained a cyst that was infected",
    "i and d of a simple abscess"
   ],
   "value_usd": 128.59,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "Incision and drainage of a simple or single abscess, cyst or boil. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.85 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.19 work + 2.53 non-facility practice expense + 0.13 malpractice RVUs, all four figures read in the CMS file on the line for CPT 10060 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 10060",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 100.54,
    "facility_setting_total_rvu": 3.01,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 3.01 facility total RVUs x $33.4009 = $100.54. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-abscess-drainage",
    "status": "PASS",
    "value_usd": 128.59,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 100.54,
      "evidence": "3.01 facility total RVUs on the unmodified line for 10060 x $33.4009 = $100.54"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 10060",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.85 total non-facility RVUs x $33.4009 = $128.59",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-wound-repair-simple",
   "label": "Stitches for a simple cut, 2.5 cm or less",
   "plain_language_synonyms": [
    "stitches for a cut",
    "simple wound repair",
    "they stitched up my cut",
    "laceration repair small",
    "sutures for a small cut",
    "closed my wound with stitches"
   ],
   "value_usd": 113.9,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "Simple repair of a superficial wound of the scalp, neck, trunk or limbs, 2.5 cm or less. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.41 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.82 work + 2.41 non-facility practice expense + 0.18 malpractice RVUs, all four figures read in the CMS file on the line for CPT 12001 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 12001",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 44.09,
    "facility_setting_total_rvu": 1.32,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 1.32 facility total RVUs x $33.4009 = $44.09. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-wound-repair-simple",
    "status": "PASS",
    "value_usd": 113.9,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 44.09,
      "evidence": "1.32 facility total RVUs on the unmodified line for 12001 x $33.4009 = $44.09"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 12001",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.41 total non-facility RVUs x $33.4009 = $113.90",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-earwax-removal",
   "label": "Ear wax removal, one ear",
   "plain_language_synonyms": [
    "ear wax removal",
    "they cleaned out my ear wax",
    "impacted cerumen removal",
    "wax taken out of my ear",
    "cerumen disimpaction one ear",
    "ear cleaning at the doctor"
   ],
   "value_usd": 47.76,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "Removal of impacted ear wax requiring instrumentation, one ear. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.43 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.59 work + 0.77 non-facility practice expense + 0.07 malpractice RVUs, all four figures read in the CMS file on the line for CPT 69210 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 69210",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 27.05,
    "facility_setting_total_rvu": 0.81,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 0.81 facility total RVUs x $33.4009 = $27.05. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-earwax-removal",
    "status": "PASS",
    "value_usd": 47.76,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 27.05,
      "evidence": "0.81 facility total RVUs on the unmodified line for 69210 x $33.4009 = $27.05"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 69210",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.43 total non-facility RVUs x $33.4009 = $47.76",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-wrist-splint",
   "label": "Fitting a wrist or forearm splint",
   "plain_language_synonyms": [
    "wrist splint fitting",
    "they put a splint on my arm",
    "short arm splint application",
    "forearm splint applied",
    "static splint for my wrist",
    "splint put on at the clinic"
   ],
   "value_usd": 79.16,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "Application of a static short arm splint from the forearm to the hand. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 2.37 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.49 work + 1.79 non-facility practice expense + 0.09 malpractice RVUs, all four figures read in the CMS file on the line for CPT 29125 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 29125",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 41.08,
    "facility_setting_total_rvu": 1.23,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 1.23 facility total RVUs x $33.4009 = $41.08. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-wrist-splint",
    "status": "PASS",
    "value_usd": 79.16,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 41.08,
      "evidence": "1.23 facility total RVUs on the unmodified line for 29125 x $33.4009 = $41.08"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 29125",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "2.37 total non-facility RVUs x $33.4009 = $79.16",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-eye-exam-est-comprehensive",
   "label": "Comprehensive eye exam, patient the practice already knows",
   "plain_language_synonyms": [
    "comprehensive eye exam established patient",
    "full eye exam with my regular eye doctor",
    "complete eye examination follow up",
    "dilated eye exam established patient",
    "yearly full eye exam",
    "comprehensive ophthalmological visit return"
   ],
   "value_usd": 127.26,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A comprehensive ophthalmological examination with initiation or continuation of a treatment plan, for an established patient. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.81 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.42 work + 2.35 non-facility practice expense + 0.04 malpractice RVUs, all four figures read in the CMS file on the line for CPT 92014 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 92014",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 62.13,
    "facility_setting_total_rvu": 1.86,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 1.86 facility total RVUs x $33.4009 = $62.13. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-eye-exam-est-comprehensive",
    "status": "PASS",
    "value_usd": 127.26,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 62.13,
      "evidence": "1.86 facility total RVUs on the unmodified line for 92014 x $33.4009 = $62.13"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 92014",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.81 total non-facility RVUs x $33.4009 = $127.26",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-eye-exam-est-intermediate",
   "label": "Follow-up eye exam, patient the practice already knows",
   "plain_language_synonyms": [
    "intermediate eye exam",
    "eye doctor follow up visit",
    "short eye check up",
    "recheck with the eye doctor",
    "intermediate ophthalmological exam established",
    "brief eye examination follow up"
   ],
   "value_usd": 90.52,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An intermediate ophthalmological examination for an established patient. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 2.71 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.92 work + 1.76 non-facility practice expense + 0.03 malpractice RVUs, all four figures read in the CMS file on the line for CPT 92012 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 92012",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 41.42,
    "facility_setting_total_rvu": 1.24,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 1.24 facility total RVUs x $33.4009 = $41.42. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-eye-exam-est-intermediate",
    "status": "PASS",
    "value_usd": 90.52,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 41.42,
      "evidence": "1.24 facility total RVUs on the unmodified line for 92012 x $33.4009 = $41.42"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 92012",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "2.71 total non-facility RVUs x $33.4009 = $90.52",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-eye-visual-field",
   "label": "Visual field test, extended",
   "plain_language_synonyms": [
    "visual field test",
    "peripheral vision test",
    "they tested my side vision",
    "automated perimetry",
    "visual field exam extended",
    "field of vision testing"
   ],
   "value_usd": 63.8,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An extended examination of the visual fields, the full automated perimetry study. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.91 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.49 work + 1.40 non-facility practice expense + 0.02 malpractice RVUs, all four figures read in the CMS file on the line for CPT 92083 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 92083",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 26.39,
    "facility_setting_total_rvu": 0.79,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 0.79 facility total RVUs on the modifier 26 line x $33.4009 = $26.39 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-eye-visual-field",
    "status": "PASS",
    "value_usd": 63.8,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 26.39,
      "evidence": "0.79 facility total RVUs on the modifier 26 line for 92083 x $33.4009 = $26.39"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 92083",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.91 total non-facility RVUs x $33.4009 = $63.80",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-eye-oct-retina",
   "label": "OCT scan of the retina",
   "plain_language_synonyms": [
    "oct of my retina",
    "retinal oct scan",
    "optical coherence tomography of the retina",
    "scan of the back of my eye",
    "retina imaging scan",
    "oct imaging posterior segment"
   ],
   "value_usd": 32.73,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "Computerised optical coherence tomography imaging of the retina, with interpretation and report. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.98 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.31 work + 0.65 non-facility practice expense + 0.02 malpractice RVUs, all four figures read in the CMS file on the line for CPT 92134 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 92134",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 17.7,
    "facility_setting_total_rvu": 0.53,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 0.53 facility total RVUs on the modifier 26 line x $33.4009 = $17.70 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-eye-oct-retina",
    "status": "PASS",
    "value_usd": 32.73,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 17.7,
      "evidence": "0.53 facility total RVUs on the modifier 26 line for 92134 x $33.4009 = $17.70"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 92134",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.98 total non-facility RVUs x $33.4009 = $32.73",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-eye-fundus-photos",
   "label": "Retinal photographs with the doctor’s reading",
   "plain_language_synonyms": [
    "fundus photography",
    "retinal photographs",
    "pictures of the back of my eye",
    "fundus photos with interpretation",
    "retina photography at the eye doctor",
    "photographs of my retina"
   ],
   "value_usd": 37.07,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "Fundus photography with interpretation and report. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.11 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.39 work + 0.70 non-facility practice expense + 0.02 malpractice RVUs, all four figures read in the CMS file on the line for CPT 92250 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the complete service — the scan itself and the radiologist reading it — as billed by a freestanding imaging centre. A hospital outpatient department is paid under a different schedule and bills its own facility charge. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 92250",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 20.37,
    "facility_setting_total_rvu": 0.61,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 0.61 facility total RVUs on the modifier 26 line x $33.4009 = $20.37 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-eye-fundus-photos",
    "status": "PASS",
    "value_usd": 37.07,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 20.37,
      "evidence": "0.61 facility total RVUs on the modifier 26 line for 92250 x $33.4009 = $20.37"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 92250",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.11 total non-facility RVUs x $33.4009 = $37.07",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-tympanometry",
   "label": "Eardrum pressure test (tympanometry)",
   "plain_language_synonyms": [
    "tympanometry",
    "eardrum pressure test",
    "they tested my ear drum movement",
    "middle ear pressure testing",
    "tymps at the audiologist",
    "impedance test of the ear"
   ],
   "value_usd": 16.03,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "Tympanometry, the impedance test of middle ear function. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.48 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.20 work + 0.27 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 92567 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 92567",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 8.68,
    "facility_setting_total_rvu": 0.26,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 0.26 facility total RVUs x $33.4009 = $8.68. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-test-tympanometry",
    "status": "PASS",
    "value_usd": 16.03,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 8.68,
      "evidence": "0.26 facility total RVUs on the unmodified line for 92567 x $33.4009 = $8.68"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 92567",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.48 total non-facility RVUs x $33.4009 = $16.03",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-test-otoacoustic",
   "label": "Inner ear emissions test, complete",
   "plain_language_synonyms": [
    "otoacoustic emissions test",
    "oae hearing test",
    "inner ear emission testing",
    "distortion product oae complete",
    "ear emissions screening complete",
    "oae test at the audiologist"
   ],
   "value_usd": 33.73,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A comprehensive evoked otoacoustic emissions test with interpretation and report. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 1.01 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.55 work + 0.44 non-facility practice expense + 0.02 malpractice RVUs, all four figures read in the CMS file on the line for CPT 92588 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 92588",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 28.72,
    "facility_setting_total_rvu": 0.86,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 0.86 facility total RVUs on the modifier 26 line x $33.4009 = $28.72 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-test-otoacoustic",
    "status": "PASS",
    "value_usd": 33.73,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 28.72,
      "evidence": "0.86 facility total RVUs on the modifier 26 line for 92588 x $33.4009 = $28.72"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 92588",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "1.01 total non-facility RVUs x $33.4009 = $33.73",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-laryngoscopy",
   "label": "Scope look at the voice box",
   "plain_language_synonyms": [
    "flexible laryngoscopy",
    "scope of my voice box",
    "ent put a camera up my nose to see my throat",
    "diagnostic laryngoscopy",
    "fiberoptic scope of the larynx",
    "ent scope of my throat"
   ],
   "value_usd": 127.26,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A diagnostic flexible fibreoptic laryngoscopy. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 3.81 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.92 work + 2.76 non-facility practice expense + 0.13 malpractice RVUs, all four figures read in the CMS file on the line for CPT 31575 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 31575",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 61.12,
    "facility_setting_total_rvu": 1.83,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 1.83 facility total RVUs x $33.4009 = $61.12. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-laryngoscopy",
    "status": "PASS",
    "value_usd": 127.26,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 61.12,
      "evidence": "1.83 facility total RVUs on the unmodified line for 31575 x $33.4009 = $61.12"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 31575",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "3.81 total non-facility RVUs x $33.4009 = $127.26",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-colposcopy-biopsy",
   "label": "Colposcopy with biopsy",
   "plain_language_synonyms": [
    "colposcopy with biopsy",
    "colposcopy after an abnormal pap",
    "they biopsied my cervix",
    "cervical biopsy with a scope",
    "colposcopy and curettage",
    "scope exam of the cervix with samples"
   ],
   "value_usd": 166,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A colposcopy of the cervix with biopsy and endocervical curettage. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 4.97 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 2.27 work + 2.30 non-facility practice expense + 0.40 malpractice RVUs, all four figures read in the CMS file on the line for CPT 57454 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 57454",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 118.91,
    "facility_setting_total_rvu": 3.56,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 3.56 facility total RVUs x $33.4009 = $118.91. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-colposcopy-biopsy",
    "status": "PASS",
    "value_usd": 166,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 118.91,
      "evidence": "3.56 facility total RVUs on the unmodified line for 57454 x $33.4009 = $118.91"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 57454",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "4.97 total non-facility RVUs x $33.4009 = $166.00",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-endometrial-biopsy",
   "label": "Biopsy of the uterine lining",
   "plain_language_synonyms": [
    "endometrial biopsy",
    "biopsy of my uterus lining",
    "they took a sample from my uterus",
    "uterine lining biopsy",
    "endometrial sampling in the office",
    "emb procedure"
   ],
   "value_usd": 98.2,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "An endometrial biopsy taken in the office without dilation. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 2.94 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 1.18 work + 1.55 non-facility practice expense + 0.21 malpractice RVUs, all four figures read in the CMS file on the line for CPT 58100 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee in a freestanding office. If it happened in a hospital-owned clinic, the hospital bills a separate facility fee on top of it. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 58100",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 55.11,
    "facility_setting_total_rvu": 1.65,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 1.65 facility total RVUs x $33.4009 = $55.11. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-endometrial-biopsy",
    "status": "PASS",
    "value_usd": 98.2,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 55.11,
      "evidence": "1.65 facility total RVUs on the unmodified line for 58100 x $33.4009 = $55.11"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 58100",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "2.94 total non-facility RVUs x $33.4009 = $98.20",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-path-tissue-exam",
   "label": "Pathologist’s examination of a biopsy sample",
   "plain_language_synonyms": [
    "pathology on my biopsy",
    "pathologist read my sample",
    "surgical pathology level 4",
    "they sent it to pathology",
    "tissue examined by a pathologist",
    "biopsy sent to the lab for reading"
   ],
   "value_usd": 70.14,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A pathologist’s gross and microscopic examination of a tissue specimen, level IV — the level most skin, cervix, endometrium and GI biopsies fall under. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 2.10 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.73 work + 1.35 non-facility practice expense + 0.02 malpractice RVUs, all four figures read in the CMS file on the line for CPT 88305 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is charged for EACH specimen. Two biopsies taken in one visit are usually two of these lines. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 88305",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 35.07,
    "facility_setting_total_rvu": 1.05,
    "facility_setting_component": "modifier 26, the professional component",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. In a hospital the clinician bills only the reading — modifier 26 — and the hospital bills the scan itself under its own outpatient system: 1.05 facility total RVUs on the modifier 26 line x $33.4009 = $35.07 to the clinician. The figure at the top of this card is the whole service in a freestanding centre, where one bill covers both halves."
   },
   "audit": {
    "id": "cms-path-tissue-exam",
    "status": "PASS",
    "value_usd": 70.14,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 35.07,
      "evidence": "1.05 facility total RVUs on the modifier 26 line for 88305 x $33.4009 = $35.07"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 88305",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "2.10 total non-facility RVUs x $33.4009 = $70.14",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-surg-knee-arthroscopy",
   "label": "Knee arthroscopy with meniscus repair or trim",
   "plain_language_synonyms": [
    "knee arthroscopy",
    "knee scope surgery",
    "arthroscopic meniscectomy",
    "they scoped my knee",
    "meniscus surgery arthroscopic",
    "knee surgery through small cuts"
   ],
   "value_usd": 515.71,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "Arthroscopy of the knee with medial or lateral meniscectomy, the surgeon’s fee. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 15.44 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 6.85 work + 7.19 non-facility practice expense + 1.40 malpractice RVUs, all four figures read in the CMS file on the line for CPT 29881 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee. If it was done in a hospital outpatient department or a surgery centre, that facility bills its own charge on top of it, and anaesthesia is billed separately again. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 29881",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-surg-knee-arthroscopy",
    "status": "PASS",
    "value_usd": 515.71,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 29881",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "15.44 total non-facility RVUs x $33.4009 = $515.71",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-surg-cataract",
   "label": "Cataract surgery with a lens implant",
   "plain_language_synonyms": [
    "cataract surgery",
    "cataract removal with lens implant",
    "they replaced my lens",
    "phacoemulsification cataract surgery",
    "cataract operation one eye",
    "lens implant surgery"
   ],
   "value_usd": 462.6,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "Extracapsular cataract removal with insertion of an intraocular lens, the surgeon’s fee. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 13.85 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 7.17 work + 6.14 non-facility practice expense + 0.54 malpractice RVUs, all four figures read in the CMS file on the line for CPT 66984 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee. If it was done in a hospital outpatient department or a surgery centre, that facility bills its own charge on top of it, and anaesthesia is billed separately again. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 66984",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-surg-cataract",
    "status": "PASS",
    "value_usd": 462.6,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 66984",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "13.85 total non-facility RVUs x $33.4009 = $462.60",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-surg-carpal-tunnel",
   "label": "Carpal tunnel release surgery",
   "plain_language_synonyms": [
    "carpal tunnel surgery",
    "carpal tunnel release",
    "they released my carpal tunnel",
    "surgery for carpal tunnel syndrome",
    "median nerve decompression at the wrist",
    "wrist surgery for carpal tunnel"
   ],
   "value_usd": 482.64,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "Neuroplasty and transposition of the median nerve at the carpal tunnel, the surgeon’s fee. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 14.45 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 4.85 work + 8.61 non-facility practice expense + 0.99 malpractice RVUs, all four figures read in the CMS file on the line for CPT 64721 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the clinician’s fee. If it was done in a hospital outpatient department or a surgery centre, that facility bills its own charge on top of it, and anaesthesia is billed separately again. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 64721",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 423.19,
    "facility_setting_total_rvu": 12.67,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 12.67 facility total RVUs x $33.4009 = $423.19. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-surg-carpal-tunnel",
    "status": "PASS",
    "value_usd": 482.64,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 423.19,
      "evidence": "12.67 facility total RVUs on the unmodified line for 64721 x $33.4009 = $423.19"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 64721",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "14.45 total non-facility RVUs x $33.4009 = $482.64",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-breast-biopsy-us",
   "label": "Breast biopsy guided by ultrasound",
   "plain_language_synonyms": [
    "ultrasound guided breast biopsy",
    "breast biopsy with ultrasound",
    "core needle biopsy of my breast",
    "they biopsied my breast with ultrasound",
    "image guided breast biopsy",
    "breast core biopsy first lesion"
   ],
   "value_usd": 475.63,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "A percutaneous breast biopsy of the first lesion with ultrasound guidance, including placement of a marker. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 14.24 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 3.02 work + 10.88 non-facility practice expense + 0.34 malpractice RVUs, all four figures read in the CMS file on the line for CPT 19083 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the biopsy. The pathologist’s examination of the sample is billed separately, usually under CPT 88305. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 19083",
   "pfs_status_indicator": "A",
   "alternates": {
    "facility_setting_physician_payment_usd": 130.6,
    "facility_setting_total_rvu": 3.91,
    "facility_setting_component": "FACILITY TOTAL on the unmodified line",
    "_facility_setting_note": "DERIVED, same file, same conversion factor. What Medicare pays the CLINICIAN for this exact code when the care happens inside a hospital-owned clinic instead of a freestanding office: 3.91 facility total RVUs x $33.4009 = $130.60. It is lower than the office figure because the practice-expense half of the payment moves to the hospital, which bills its own facility fee on top."
   },
   "audit": {
    "id": "cms-proc-breast-biopsy-us",
    "status": "PASS",
    "value_usd": 475.63,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [
     {
      "key": "facility_setting_physician_payment_usd",
      "status": "PASS",
      "value_usd": 130.6,
      "evidence": "3.91 facility total RVUs on the unmodified line for 19083 x $33.4009 = $130.60"
     }
    ],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 19083",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "14.24 total non-facility RVUs x $33.4009 = $475.63",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-proc-vaccine-admin",
   "label": "Giving a vaccine (the administration fee)",
   "plain_language_synonyms": [
    "vaccine administration fee",
    "fee for giving me a shot of vaccine",
    "immunization administration",
    "they charged to administer the vaccine",
    "vaccine injection fee",
    "administration of one vaccine"
   ],
   "value_usd": 22.04,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, national (geographic practice cost indices set to 1.000)",
   "population": "Medicare Part B fee-for-service beneficiaries",
   "coverage_statement": "The fee for administering one vaccine. The vaccine itself is billed separately. HOW THIS NUMBER WAS MADE: CMS does not publish a dollar column in the physician fee schedule. It publishes Relative Value Units and a conversion factor and defines the payment as their product. This figure is 0.66 Total non-facility RVUs x $33.4009 (the CY2026 conversion factor for a non-qualifying APM), at national geographic practice cost indices of 1.000. The RVU total is itself the sum of 0.17 work + 0.48 non-facility practice expense + 0.01 malpractice RVUs, all four figures read in the CMS file on the line for CPT 90471 (status indicator A, active and separately payable). The multiplication is ours, so this is marked DERIVED rather than VERIFIED. You can redo it yourself. This is the fee for GIVING the vaccine. The vaccine product is billed separately. Who this describes: people on Medicare fee-for-service — that is, people 65 and older, plus people under 65 who qualified through 24 or more months of disability benefits or who have end-stage kidney disease. Who it does NOT describe: people on a plan from work, a Marketplace plan, Medicaid, or no insurance, and those usually pay more than Medicare, so read this as the floor, not your bill. Read it as a PRICE FLOOR, not as your bill: commercial insurance normally pays more than Medicare, and an uninsured person is billed the provider’s charge instead, which is routinely several times this amount.",
   "source_title": "CMS, CY2026 National Physician Fee Schedule Relative Value File (RVU26C, July release, published 2026-06-30)",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "DERIVED",
   "code": "CPT 90471",
   "pfs_status_indicator": "A",
   "audit": {
    "id": "cms-proc-vaccine-admin",
    "status": "PASS",
    "value_usd": 22.04,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "DERIVED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 90471",
    "loinc": null,
    "check": "PFS re-derivation, non-facility setting",
    "evidence": "0.66 total non-facility RVUs x $33.4009 = $22.04",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/rvu26c",
    "source_key": "rvu",
    "extras": []
   }
  },
  {
   "id": "cms-lab-venipuncture",
   "label": "The needle stick to collect the blood (venipuncture)",
   "plain_language_synonyms": [
    "venipuncture fee",
    "phlebotomy charge",
    "the charge for taking the blood",
    "needle stick to collect blood",
    "specimen collection by venipuncture",
    "fee for collecting a blood sample"
   ],
   "value_usd": 9.34,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The separate fee for collecting a blood sample by needle, charged on top of every test run on that sample. HOW THIS NUMBER WAS MADE: it was READ, not computed — $9.34 is the payment amount printed on the row for CPT 36415 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 36415",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-venipuncture",
    "status": "PASS",
    "value_usd": 9.34,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 36415",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 36415 pays $9.34 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-urinalysis-auto",
   "label": "Urine dipstick test, automated, no microscope",
   "plain_language_synonyms": [
    "automated urinalysis",
    "urine dipstick without microscope",
    "quick urine test",
    "automated urine test strip",
    "urinalysis by machine",
    "dipstick urine screen"
   ],
   "value_usd": 2.25,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "An automated dipstick urinalysis without microscopic examination. HOW THIS NUMBER WAS MADE: it was READ, not computed — $2.25 is the payment amount printed on the row for CPT 81003 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 81003",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-urinalysis-auto",
    "status": "PASS",
    "value_usd": 2.25,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 81003",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 81003 pays $2.25 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-strep-rapid",
   "label": "Rapid strep test",
   "plain_language_synonyms": [
    "rapid strep test",
    "strep throat swab",
    "throat swab for strep",
    "quick strep test",
    "strep a rapid antigen test",
    "swabbed my throat for strep"
   ],
   "value_usd": 16.53,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A rapid antigen test for group A streptococcus. HOW THIS NUMBER WAS MADE: it was READ, not computed — $16.53 is the payment amount printed on the row for CPT 87880 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 87880",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-strep-rapid",
    "status": "PASS",
    "value_usd": 16.53,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 87880",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 87880 pays $16.53 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-flu-rapid",
   "label": "Rapid flu test",
   "plain_language_synonyms": [
    "rapid flu test",
    "influenza swab",
    "quick flu test",
    "flu antigen test",
    "nose swab for the flu",
    "rapid influenza antigen test"
   ],
   "value_usd": 16.55,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A rapid antigen test for influenza. HOW THIS NUMBER WAS MADE: it was READ, not computed — $16.55 is the payment amount printed on the row for CPT 87804 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 87804",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-flu-rapid",
    "status": "PASS",
    "value_usd": 16.55,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 87804",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 87804 pays $16.55 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-strep-naat",
   "label": "Strep throat test by DNA (molecular)",
   "plain_language_synonyms": [
    "molecular strep test",
    "strep pcr test",
    "dna strep throat test",
    "strep a nucleic acid test",
    "send out strep test",
    "pcr swab for strep"
   ],
   "value_usd": 35.09,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A nucleic acid amplification test for group A streptococcus. HOW THIS NUMBER WAS MADE: it was READ, not computed — $35.09 is the payment amount printed on the row for CPT 87651 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 87651",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-strep-naat",
    "status": "PASS",
    "value_usd": 35.09,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 87651",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 87651 pays $35.09 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-hepatitis-panel",
   "label": "Acute hepatitis panel",
   "plain_language_synonyms": [
    "acute hepatitis panel",
    "hepatitis panel blood test",
    "tested me for all the hepatitis viruses",
    "hepatitis screening panel",
    "full hepatitis blood panel",
    "hep panel"
   ],
   "value_usd": 47.63,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The acute hepatitis panel, which bundles hepatitis A IgM, hepatitis B core IgM, hepatitis B surface antigen and hepatitis C antibody. HOW THIS NUMBER WAS MADE: it was READ, not computed — $47.63 is the payment amount printed on the row for CPT 80074 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 80074",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-hepatitis-panel",
    "status": "PASS",
    "value_usd": 47.63,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 80074",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 80074 pays $47.63 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-celiac-ttg",
   "label": "Celiac antibody test (tissue transglutaminase)",
   "plain_language_synonyms": [
    "celiac blood test",
    "tissue transglutaminase antibody",
    "ttg iga test",
    "tested me for celiac disease",
    "gluten antibody blood test",
    "celiac screening antibody"
   ],
   "value_usd": 11.53,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A tissue transglutaminase antibody test, one immunoglobulin class, the first-line blood test for coeliac disease. HOW THIS NUMBER WAS MADE: it was READ, not computed — $11.53 is the payment amount printed on the row for CPT 86364 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 86364",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-celiac-ttg",
    "status": "PASS",
    "value_usd": 11.53,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 86364",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 86364 pays $11.53 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-cortisol",
   "label": "Cortisol level",
   "plain_language_synonyms": [
    "cortisol test",
    "morning cortisol level",
    "stress hormone blood test",
    "total cortisol blood test",
    "checked my cortisol",
    "adrenal cortisol level"
   ],
   "value_usd": 16.3,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A total cortisol measurement. HOW THIS NUMBER WAS MADE: it was READ, not computed — $16.30 is the payment amount printed on the row for CPT 82533 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 82533",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-cortisol",
    "status": "PASS",
    "value_usd": 16.3,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 82533",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 82533 pays $16.30 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-total-testosterone",
   "label": "Total testosterone level",
   "plain_language_synonyms": [
    "total testosterone test",
    "testosterone blood test",
    "checked my total testosterone",
    "male hormone level test",
    "serum testosterone total",
    "testosterone lab"
   ],
   "value_usd": 25.81,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A total testosterone measurement. HOW THIS NUMBER WAS MADE: it was READ, not computed — $25.81 is the payment amount printed on the row for CPT 84403 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 84403",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-total-testosterone",
    "status": "PASS",
    "value_usd": 25.81,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 84403",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 84403 pays $25.81 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-psa",
   "label": "PSA (prostate) test",
   "plain_language_synonyms": [
    "psa test",
    "prostate specific antigen",
    "prostate blood test",
    "checked my psa",
    "psa screening blood test",
    "total psa level"
   ],
   "value_usd": 18.39,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A total prostate specific antigen measurement. HOW THIS NUMBER WAS MADE: it was READ, not computed — $18.39 is the payment amount printed on the row for CPT 84153 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 84153",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-psa",
    "status": "PASS",
    "value_usd": 18.39,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 84153",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 84153 pays $18.39 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-iron",
   "label": "Serum iron level",
   "plain_language_synonyms": [
    "serum iron test",
    "iron level blood test",
    "checked my iron",
    "iron blood level",
    "serum iron lab",
    "tested my iron level"
   ],
   "value_usd": 6.47,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A serum iron measurement. HOW THIS NUMBER WAS MADE: it was READ, not computed — $6.47 is the payment amount printed on the row for CPT 83540 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 83540",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-iron",
    "status": "PASS",
    "value_usd": 6.47,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 83540",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 83540 pays $6.47 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-lactate",
   "label": "Lactate (lactic acid) level",
   "plain_language_synonyms": [
    "lactate level",
    "lactic acid blood test",
    "checked my lactate",
    "serum lactate test",
    "lactic acid level lab",
    "blood lactate measurement"
   ],
   "value_usd": 11.57,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A lactic acid measurement. HOW THIS NUMBER WAS MADE: it was READ, not computed — $11.57 is the payment amount printed on the row for CPT 83605 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 83605",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-lactate",
    "status": "PASS",
    "value_usd": 11.57,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 83605",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 83605 pays $11.57 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-thyroid-antibodies",
   "label": "Thyroid antibody test (TPO / microsomal)",
   "plain_language_synonyms": [
    "thyroid antibody test",
    "tpo antibody",
    "thyroid peroxidase antibodies",
    "microsomal antibody test",
    "hashimoto antibody test",
    "antibodies against my thyroid"
   ],
   "value_usd": 14.55,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A microsomal (thyroid peroxidase) antibody test, one of the antibodies used to look for autoimmune thyroid disease. HOW THIS NUMBER WAS MADE: it was READ, not computed — $14.55 is the payment amount printed on the row for CPT 86376 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 86376",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-thyroid-antibodies",
    "status": "PASS",
    "value_usd": 14.55,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 86376",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 86376 pays $14.55 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-ccp",
   "label": "CCP antibody test (rheumatoid arthritis)",
   "plain_language_synonyms": [
    "ccp antibody test",
    "anti ccp test",
    "cyclic citrullinated peptide antibody",
    "rheumatoid arthritis antibody test",
    "tested me for rheumatoid arthritis",
    "acpa blood test"
   ],
   "value_usd": 12.95,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A cyclic citrullinated peptide antibody test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $12.95 is the payment amount printed on the row for CPT 86200 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 86200",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-ccp",
    "status": "PASS",
    "value_usd": 12.95,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 86200",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 86200 pays $12.95 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-rheumatoid-factor",
   "label": "Rheumatoid factor test",
   "plain_language_synonyms": [
    "rheumatoid factor",
    "rf blood test",
    "rheumatoid factor quantitative",
    "tested my rheumatoid factor",
    "rf titre blood test",
    "rheumatoid factor level"
   ],
   "value_usd": 5.67,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A quantitative rheumatoid factor measurement. HOW THIS NUMBER WAS MADE: it was READ, not computed — $5.67 is the payment amount printed on the row for CPT 86431 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 86431",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-rheumatoid-factor",
    "status": "PASS",
    "value_usd": 5.67,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 86431",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 86431 pays $5.67 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-homocysteine",
   "label": "Homocysteine level",
   "plain_language_synonyms": [
    "homocysteine test",
    "homocysteine blood level",
    "checked my homocysteine",
    "serum homocysteine",
    "homocysteine lab test",
    "homocysteine measurement"
   ],
   "value_usd": 17.92,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A homocysteine measurement. HOW THIS NUMBER WAS MADE: it was READ, not computed — $17.92 is the payment amount printed on the row for CPT 83090 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 83090",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-homocysteine",
    "status": "PASS",
    "value_usd": 17.92,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 83090",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 83090 pays $17.92 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-uric-acid",
   "label": "Uric acid level (gout test)",
   "plain_language_synonyms": [
    "uric acid test",
    "gout blood test",
    "checked my uric acid",
    "serum uric acid",
    "urate blood level",
    "uric acid measurement"
   ],
   "value_usd": 4.52,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A blood uric acid measurement. HOW THIS NUMBER WAS MADE: it was READ, not computed — $4.52 is the payment amount printed on the row for CPT 84550 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 84550",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-uric-acid",
    "status": "PASS",
    "value_usd": 4.52,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 84550",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 84550 pays $4.52 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-creatinine",
   "label": "Creatinine (kidney function) test",
   "plain_language_synonyms": [
    "creatinine test",
    "kidney function blood test creatinine",
    "serum creatinine level",
    "checked my creatinine",
    "creatinine blood level",
    "creatinine measurement"
   ],
   "value_usd": 5.12,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A serum creatinine measurement. HOW THIS NUMBER WAS MADE: it was READ, not computed — $5.12 is the payment amount printed on the row for CPT 82565 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 82565",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-creatinine",
    "status": "PASS",
    "value_usd": 5.12,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 82565",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 82565 pays $5.12 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-bun",
   "label": "BUN (urea nitrogen) test",
   "plain_language_synonyms": [
    "bun test",
    "urea nitrogen blood test",
    "blood urea nitrogen level",
    "checked my bun",
    "serum urea nitrogen",
    "bun measurement"
   ],
   "value_usd": 3.95,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A blood urea nitrogen measurement. HOW THIS NUMBER WAS MADE: it was READ, not computed — $3.95 is the payment amount printed on the row for CPT 84520 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 84520",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-bun",
    "status": "PASS",
    "value_usd": 3.95,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 84520",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 84520 pays $3.95 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-hepatic-panel",
   "label": "Liver panel (hepatic function panel)",
   "plain_language_synonyms": [
    "liver panel",
    "liver function tests",
    "lft blood test",
    "hepatic function panel",
    "checked my liver enzymes",
    "liver blood panel"
   ],
   "value_usd": 8.17,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The hepatic function panel, which bundles albumin, total and direct bilirubin, alkaline phosphatase, total protein, ALT and AST. HOW THIS NUMBER WAS MADE: it was READ, not computed — $8.17 is the payment amount printed on the row for CPT 80076 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 80076",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-hepatic-panel",
    "status": "PASS",
    "value_usd": 8.17,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 80076",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 80076 pays $8.17 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-renal-panel",
   "label": "Kidney panel (renal function panel)",
   "plain_language_synonyms": [
    "kidney panel",
    "renal function panel",
    "kidney blood panel",
    "renal panel blood test",
    "panel to check my kidneys",
    "kidney function panel test"
   ],
   "value_usd": 8.68,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The renal function panel, which bundles albumin, calcium, carbon dioxide, chloride, creatinine, glucose, phosphorus, potassium, sodium and urea nitrogen. HOW THIS NUMBER WAS MADE: it was READ, not computed — $8.68 is the payment amount printed on the row for CPT 80069 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 80069",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-renal-panel",
    "status": "PASS",
    "value_usd": 8.68,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 80069",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 80069 pays $8.68 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-electrolytes",
   "label": "Electrolyte panel",
   "plain_language_synonyms": [
    "electrolyte panel",
    "checked my electrolytes",
    "electrolytes blood test",
    "sodium potassium chloride panel",
    "lytes panel",
    "electrolyte blood panel"
   ],
   "value_usd": 7.01,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "The electrolyte panel, which bundles carbon dioxide, chloride, potassium and sodium. HOW THIS NUMBER WAS MADE: it was READ, not computed — $7.01 is the payment amount printed on the row for CPT 80051 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 80051",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-electrolytes",
    "status": "PASS",
    "value_usd": 7.01,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 80051",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 80051 pays $7.01 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-hemoglobin-only",
   "label": "Hemoglobin level on its own",
   "plain_language_synonyms": [
    "hemoglobin level test",
    "haemoglobin blood level",
    "checked my hemoglobin only",
    "hgb blood test",
    "hemoglobin measurement alone",
    "single hemoglobin test"
   ],
   "value_usd": 2.37,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A haemoglobin measurement on its own, without the rest of a blood count. HOW THIS NUMBER WAS MADE: it was READ, not computed — $2.37 is the payment amount printed on the row for CPT 85018 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 85018",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-hemoglobin-only",
    "status": "PASS",
    "value_usd": 2.37,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 85018",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 85018 pays $2.37 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-chlamydia",
   "label": "Chlamydia test (molecular)",
   "plain_language_synonyms": [
    "chlamydia test",
    "chlamydia dna test",
    "tested me for chlamydia",
    "chlamydia nucleic acid test",
    "chlamydia swab or urine test",
    "ct molecular test"
   ],
   "value_usd": 35.09,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A nucleic acid amplification test for Chlamydia trachomatis. HOW THIS NUMBER WAS MADE: it was READ, not computed — $35.09 is the payment amount printed on the row for CPT 87491 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 87491",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-chlamydia",
    "status": "PASS",
    "value_usd": 35.09,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 87491",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 87491 pays $35.09 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-gonorrhea",
   "label": "Gonorrhea test (molecular)",
   "plain_language_synonyms": [
    "gonorrhea test",
    "gonorrhoea dna test",
    "tested me for gonorrhea",
    "gonorrhea nucleic acid test",
    "gc molecular test",
    "gonorrhea swab or urine test"
   ],
   "value_usd": 35.09,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A nucleic acid amplification test for Neisseria gonorrhoeae. HOW THIS NUMBER WAS MADE: it was READ, not computed — $35.09 is the payment amount printed on the row for CPT 87591 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 87591",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-gonorrhea",
    "status": "PASS",
    "value_usd": 35.09,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 87591",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 87591 pays $35.09 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-bacterial-culture",
   "label": "Bacterial culture of a sample",
   "plain_language_synonyms": [
    "bacterial culture",
    "wound culture",
    "throat culture sent to the lab",
    "culture of a specimen",
    "aerobic culture of a sample",
    "they cultured the swab"
   ],
   "value_usd": 8.62,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "An aerobic bacterial culture of a specimen other than blood, stool or urine, with isolation and identification. HOW THIS NUMBER WAS MADE: it was READ, not computed — $8.62 is the payment amount printed on the row for CPT 87070 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 87070",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-bacterial-culture",
    "status": "PASS",
    "value_usd": 8.62,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 87070",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 87070 pays $8.62 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-ova-parasites",
   "label": "Stool test for parasites (ova and parasites)",
   "plain_language_synonyms": [
    "ova and parasites test",
    "o and p stool test",
    "stool test for parasites",
    "parasite stool exam",
    "tested my stool for parasites",
    "ova parasite smear"
   ],
   "value_usd": 8.9,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "An ova and parasites examination of stool with concentration and identification. HOW THIS NUMBER WAS MADE: it was READ, not computed — $8.90 is the payment amount printed on the row for CPT 87177 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 87177",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-ova-parasites",
    "status": "PASS",
    "value_usd": 8.9,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 87177",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 87177 pays $8.90 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-fit-stool",
   "label": "Stool blood test (FIT)",
   "plain_language_synonyms": [
    "fit stool test",
    "fecal immunochemical test",
    "stool card for blood",
    "faecal occult blood immunoassay",
    "stool test for hidden blood",
    "colon screening stool test"
   ],
   "value_usd": 15.92,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A faecal occult blood test by immunoassay, the stool card used for colorectal screening. HOW THIS NUMBER WAS MADE: it was READ, not computed — $15.92 is the payment amount printed on the row for CPT 82274 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 82274",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-fit-stool",
    "status": "PASS",
    "value_usd": 15.92,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 82274",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 82274 pays $15.92 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-cologuard",
   "label": "Stool DNA colon screening test",
   "plain_language_synonyms": [
    "stool dna test for colon cancer",
    "cologuard test",
    "multitarget stool dna screening",
    "dna stool colon screen",
    "colon cancer stool dna test",
    "stool test with dna analysis"
   ],
   "value_usd": 508.87,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A multitarget stool DNA colorectal cancer screening test with an algorithmic result. HOW THIS NUMBER WAS MADE: it was READ, not computed — $508.87 is the payment amount printed on the row for CPT 81528 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 81528",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-cologuard",
    "status": "PASS",
    "value_usd": 508.87,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 81528",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 81528 pays $508.87 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-hcg-quant",
   "label": "Pregnancy hormone level, quantitative (beta hCG)",
   "plain_language_synonyms": [
    "quantitative hcg",
    "beta hcg blood level",
    "quantitative pregnancy blood test",
    "hcg number blood test",
    "serial beta hcg",
    "chorionic gonadotropin quantitative"
   ],
   "value_usd": 15.05,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A quantitative chorionic gonadotropin measurement. HOW THIS NUMBER WAS MADE: it was READ, not computed — $15.05 is the payment amount printed on the row for CPT 84702 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 84702",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-hcg-quant",
    "status": "PASS",
    "value_usd": 15.05,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 84702",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 84702 pays $15.05 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-hcg-qual",
   "label": "Pregnancy test, yes or no (qualitative hCG)",
   "plain_language_synonyms": [
    "qualitative hcg",
    "blood pregnancy test yes or no",
    "pregnancy test at the clinic",
    "hcg screen qualitative",
    "simple pregnancy blood test",
    "chorionic gonadotropin qualitative"
   ],
   "value_usd": 7.52,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A qualitative chorionic gonadotropin test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $7.52 is the payment amount printed on the row for CPT 84703 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 84703",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-hcg-qual",
    "status": "PASS",
    "value_usd": 7.52,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 84703",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 84703 pays $7.52 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-insulin",
   "label": "Insulin level",
   "plain_language_synonyms": [
    "insulin level test",
    "fasting insulin blood test",
    "checked my insulin",
    "serum insulin measurement",
    "insulin lab test",
    "insulin blood level"
   ],
   "value_usd": 11.43,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "An insulin measurement. HOW THIS NUMBER WAS MADE: it was READ, not computed — $11.43 is the payment amount printed on the row for CPT 83525 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 83525",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-insulin",
    "status": "PASS",
    "value_usd": 11.43,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 83525",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 83525 pays $11.43 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-gtt",
   "label": "Glucose tolerance test",
   "plain_language_synonyms": [
    "glucose tolerance test",
    "gtt drink test",
    "drank the sugar drink for a test",
    "oral glucose tolerance test",
    "three hour glucose test",
    "sugar tolerance blood test"
   ],
   "value_usd": 12.87,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A glucose tolerance test with three specimens. HOW THIS NUMBER WAS MADE: it was READ, not computed — $12.87 is the payment amount printed on the row for CPT 82951 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 82951",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-gtt",
    "status": "PASS",
    "value_usd": 12.87,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 82951",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 82951 pays $12.87 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-free-t3",
   "label": "Free T3 thyroid hormone",
   "plain_language_synonyms": [
    "free t3 test",
    "ft3 level",
    "free triiodothyronine",
    "checked my free t3",
    "free t3 thyroid level",
    "ft3 blood test"
   ],
   "value_usd": 16.94,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A free triiodothyronine measurement. HOW THIS NUMBER WAS MADE: it was READ, not computed — $16.94 is the payment amount printed on the row for CPT 84481 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 84481",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-free-t3",
    "status": "PASS",
    "value_usd": 16.94,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 84481",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 84481 pays $16.94 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-total-t4",
   "label": "Total T4 thyroid hormone",
   "plain_language_synonyms": [
    "total t4 test",
    "total thyroxine level",
    "t4 total blood test",
    "checked my total t4",
    "thyroxine total measurement",
    "total t4 thyroid lab"
   ],
   "value_usd": 6.87,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A total thyroxine measurement. HOW THIS NUMBER WAS MADE: it was READ, not computed — $6.87 is the payment amount printed on the row for CPT 84436 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 84436",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-total-t4",
    "status": "PASS",
    "value_usd": 6.87,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 84436",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 84436 pays $6.87 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-blood-type",
   "label": "Blood type (ABO)",
   "plain_language_synonyms": [
    "blood typing",
    "abo blood type test",
    "found out my blood type",
    "blood group test",
    "typed my blood",
    "abo typing"
   ],
   "value_usd": 2.99,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "An ABO blood typing by serologic method. HOW THIS NUMBER WAS MADE: it was READ, not computed — $2.99 is the payment amount printed on the row for CPT 86900 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 86900",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-blood-type",
    "status": "PASS",
    "value_usd": 2.99,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 86900",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 86900 pays $2.99 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-microalbumin",
   "label": "Urine microalbumin",
   "plain_language_synonyms": [
    "urine microalbumin",
    "microalbumin test",
    "albumin in my urine",
    "urine albumin quantitative",
    "kidney protein urine test",
    "microalbuminuria test"
   ],
   "value_usd": 5.78,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A quantitative urine albumin measurement. HOW THIS NUMBER WAS MADE: it was READ, not computed — $5.78 is the payment amount printed on the row for CPT 82043 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 82043",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-microalbumin",
    "status": "PASS",
    "value_usd": 5.78,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 82043",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 82043 pays $5.78 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-mono",
   "label": "Mono spot test",
   "plain_language_synonyms": [
    "mono spot test",
    "monospot",
    "tested me for mononucleosis",
    "heterophile antibody test",
    "mono screen blood test",
    "glandular fever test"
   ],
   "value_usd": 5.18,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A heterophile antibody screen, the mono spot test. HOW THIS NUMBER WAS MADE: it was READ, not computed — $5.18 is the payment amount printed on the row for CPT 86308 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 86308",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-mono",
    "status": "PASS",
    "value_usd": 5.18,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 86308",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 86308 pays $5.18 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-h-pylori-ab",
   "label": "H. pylori antibody blood test",
   "plain_language_synonyms": [
    "h pylori antibody",
    "helicobacter blood test",
    "tested my blood for h pylori",
    "h pylori serology",
    "stomach bacteria blood test",
    "helicobacter pylori antibody"
   ],
   "value_usd": 16.85,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A Helicobacter pylori antibody measurement. HOW THIS NUMBER WAS MADE: it was READ, not computed — $16.85 is the payment amount printed on the row for CPT 86677 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 86677",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-h-pylori-ab",
    "status": "PASS",
    "value_usd": 16.85,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 86677",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 86677 pays $16.85 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-h-pylori-breath",
   "label": "H. pylori breath test",
   "plain_language_synonyms": [
    "h pylori breath test",
    "urea breath test",
    "breath test for stomach bacteria",
    "c 13 breath test",
    "helicobacter breath test",
    "blew into a bag for h pylori"
   ],
   "value_usd": 67.36,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A Helicobacter pylori breath test using non-radioactive carbon-13 urea. HOW THIS NUMBER WAS MADE: it was READ, not computed — $67.36 is the payment amount printed on the row for CPT 83013 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 83013",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-h-pylori-breath",
    "status": "PASS",
    "value_usd": 67.36,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 83013",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 83013 pays $67.36 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  },
  {
   "id": "cms-lab-glucose-fingerstick",
   "label": "Finger-stick blood sugar at the clinic",
   "plain_language_synonyms": [
    "finger stick blood sugar",
    "glucose by glucometer",
    "they pricked my finger for sugar",
    "point of care glucose test",
    "fingerstick glucose at the office",
    "bedside blood sugar check"
   ],
   "value_usd": 3.28,
   "out_of_pocket_usd": null,
   "basis": "allowed_amount",
   "attribution": "gross",
   "summable": true,
   "mutually_exclusive_with": [],
   "bundles_ancillaries": false,
   "year": "2026",
   "geography": "United States, one national rate (the lab fee schedule has no geographic adjustment)",
   "population": "Medicare Part B beneficiaries; any laboratory billing Medicare",
   "coverage_statement": "A blood glucose measurement by a device cleared for home use, the finger-stick reading taken at a visit. HOW THIS NUMBER WAS MADE: it was READ, not computed — $3.28 is the payment amount printed on the row for CPT 82962 in the CY2026 Quarter 3 clinical laboratory fee schedule, so this figure is VERIFIED rather than derived. There is one national rate with no geographic adjustment, because Congress set these rates from reported private-payer rates. Medicare pays 100 percent of this rate and a Medicare patient owes nothing for it — services on the clinical laboratory fee schedule carry no deductible and no coinsurance under Part B. That $0 is MEDICARE-ONLY and must never be copied into an out-of-pocket column. Who this describes: people on Medicare fee-for-service, and any laboratory billing Medicare. Who it does NOT describe: if you have private insurance you pay your deductible and then coinsurance on a negotiated rate that is normally higher than this one; if you are uninsured you are billed the laboratory’s charge, which for common tests runs several times this rate. Read it as a PRICE FLOOR, not as your bill.",
   "source_title": "CMS, Clinical Laboratory Fee Schedule, CY2026 Quarter 3 (PUF_CLFS_CY2026_Q3V1), effective 2026-01-01",
   "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
   "agency": "CMS",
   "agency_display": "Centers for Medicare & Medicaid Services",
   "confidence": "VERIFIED",
   "code": "CPT 82962",
   "alternates": {
    "medicare_beneficiary_cost_share_usd": 0,
    "_cost_share_note": "MEDICARE-ONLY $0. Services on the clinical laboratory fee schedule carry no Part B deductible or coinsurance. It must never populate an out-of-pocket column."
   },
   "audit": {
    "id": "cms-lab-glucose-fingerstick",
    "status": "PASS",
    "value_usd": 3.28,
    "basis": "allowed_amount",
    "alternates": [],
    "facility": [],
    "frequency": [],
    "confidence": "VERIFIED",
    "agency": "Centers for Medicare & Medicaid Services",
    "code": "CPT 82962",
    "loinc": null,
    "check": "CLFS lookup",
    "evidence": "CPT 82962 pays $3.28 on the CY2026 Q3 file",
    "source_url": "https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files/26clabq3",
    "source_key": "clfs",
    "extras": []
   }
  }
 ]
}