Payment Calculator
Start with a provider, payer, and code to see facility-specific reimbursement context from published Medicare and Medi-Cal fee schedules. This is the first public module in the broader RCI Revenue Cycle Workspace.
What it calculates
Outpatient — CPT / HCPCS codes
Physician payment
Work, practice expense, and malpractice RVUs × geographic GPCI adjustors × the CMS conversion factor.
Facility (outpatient) payment
OPPS Ambulatory Payment Classification rate split into labor (wage-index adjusted) and non-labor portions.
Clinical lab payment
National rate from the Medicare Clinical Lab Fee Schedule for HCPCS lab codes.
DME payment
Durable medical equipment rate for the provider's state, with rural vs. non-rural determination.
Inpatient — DRG codes
Medicare MS-DRG payment
Operating base (labor × wage index + non-labor) plus capital base (federal rate × GAF), both scaled by the DRG relative weight.
Medi-Cal APR-DRG payment
Hospital-specific base rate × casemix weight × policy adjustor, with high-side/low-side outlier logic and transfer adjustments.
Supported payers
Medicare
All US providersPulls from CMS fee schedules covering every Medicare-certified hospital and physician group in the country. Wage index, CBSA, COLA, GAF, and quality adjustment flags are loaded per provider from the IPPS Impact File.
- Physician payment: MPFS RVU-based with GPCI locality adjustment
- Outpatient facility: OPPS Addendum B rates
- Inpatient: MS-DRG relative weights, FY 2026
- Lab: Clinical Lab Fee Schedule
- DME: DMEPOS fee schedule by state
Medi-Cal
California providersUses California DHCS fee schedules for outpatient CPT/HCPCS codes and inpatient APR-DRG payments. Rates vary by provider type for outpatient and by hospital-specific wage index for inpatient.
- Outpatient: statewide rates by provider type (HOPD, clinic, podiatrist, CRNA)
- Child vs. adult rate variants where applicable
- Emergency room rate conversion when applicable
- Inpatient: APR-DRG with outlier and transfer adjustments
- Hospital-specific cost-to-charge ratios and base rates
How it works
Select a payer and enter a provider
Choose Medicare or Medi-Cal, then look up any provider by CCN number or hospital name. The calculator loads that provider's wage index, geographic adjustors, and payment flags automatically.
Enter a code
Type a CPT or HCPCS code for outpatient lookups, or an MS-DRG / APR-DRG code for inpatient. Add an optional modifier, date of service, or place of service code to refine the result.
Get the full calculation
Every intermediate value is shown — RVUs, GPCI adjustors, wage index, APC rates, DRG weights. The data source file and version is cited so you can trace any number back to the published fee schedule.
Data sources
All data is sourced directly from CMS and the California DHCS. Every result cites the exact file version used.
| Source |
|---|
Medicare Inpatient Hospital Payment Rates · FY 2026 Wage indexes, geographic adjustments, and quality flags for every Medicare-certified hospital. |
Medicare Physician Fee Schedule — Relative Value Units · CY 2026 Work, practice expense, and malpractice RVU values behind every CPT payment. |
Medicare Hospital Outpatient Payment Rates · CY 2026 APC rates used to calculate facility payments for outpatient procedures. |
Medicare Clinical Lab Fee Schedule · CY 2026 National rates for lab tests billed with HCPCS codes. |
Medicare DME Fee Schedule · 2026 Rates for durable medical equipment, prosthetics, orthotics, and supplies — by state and rural/non-rural status. |
Medicare Inpatient DRG Weights & Length-of-Stay Table · FY 2026 Relative weights and expected length of stay for every MS-DRG. |
Medicare Geographic Practice Cost Index · CY 2026 Locality-level cost adjusters for work, practice expense, and malpractice used in physician payment calculations. |
Medi-Cal Outpatient Payment Rates · SFY 2025–26 California's statewide rates for CPT/HCPCS codes by provider type. |
Medi-Cal Inpatient APR-DRG Rates & Hospital File · SFY 2025–26 California inpatient DRG rates with hospital-specific wage adjustments and outlier thresholds. |
Which payer base should we model next?
We're expanding beyond public Medicare and Medi-Cal data into client-specific payer models. Tell us which commercial carriers, state Medicaid programs, managed care plans, or contract rules matter most for your workspace.