Estimate insurance vs patient responsibility.
Reference estimate. Always verify against official sources.
The tool looks up the base fee for the CPT code you picked, multiplies it by the payer's allowed-amount factor to get an adjusted total, then splits that total between insurer and patient using the responsibility percentage you entered.
These three runs use codes and factors already built into the calculator, so you can trace every dollar back to a number on this page.
| Code & payer | Adjusted total | Insurance pays | Patient pays |
|---|---|---|---|
| 99214 ($168), Private, 20% | $159.60 | $127.68 | $31.92 |
| 99395 ($192), Medicare, 20% | $153.60 | $122.88 | $30.72 |
| 85025 ($11), Uninsured, 100% | $11.00 | $0.00 | $11.00 |
Compare rows one and three: Medicare's 80% factor still leaves the patient owing less than an uninsured visit at a much smaller list price, because the uninsured column has no adjustment at all and the patient covers the entire fee.
Every code in the dropdown above and its reference fee, listed together for quick scanning.
| CPT code | Description | Reference fee |
|---|---|---|
| 99213 | Office visit, established (15-29 min) | $110 |
| 99214 | Office visit, established (30-39 min) | $168 |
| 99203 | Office visit, new patient (30-44 min) | $167 |
| 99204 | Office visit, new patient (45-59 min) | $234 |
| 99395 | Annual physical (age 18-39) | $192 |
| 85025 | Complete blood count | $11 |
| 80053 | Comprehensive metabolic panel | $14 |
| 93000 | Electrocardiogram, 12 leads | $19 |
| 73060 | Knee X-ray, 2 views | $68 |
Dosing and staffing math live in the same toolbox as this calculator.
Each payer negotiates its own allowed amount with a provider, and that contracted rate is usually well below the fee the provider bills. Medicare's 80% factor and Medicaid's 65% factor in this tool are typical examples of how far below list price the actual reimbursement can land.
It's the share of the allowed amount, not the original fee, that the patient owes after insurance pays its portion. It's usually made up of a copay, coinsurance percentage, or remaining deductible, and it can change visit to visit depending on where the patient stands against their deductible.
No. The insurance-type factors here are single representative percentages standing in for a huge range of real contracts. Your actual bill depends on your specific plan's negotiated rate, your deductible status, and which CPT codes actually appear on the claim.
No. It's a rough estimate meant to show how the math behind a bill works, not a substitute for your insurer's explanation of benefits or your provider's billing office. For an exact number, ask your provider for a good-faith estimate before the visit.
