How outpatient procedure prices work

Every bill has layers. Ask for each one.

For imaging, the layers are the technical component (equipment, technologist, supplies) and the professional component (the radiologist or cardiologist who interprets the study). For endoscopy, add the facility fee for the procedure room and recovery, plus anesthesia and pathology when they apply. A quote that names only one layer is not an all-in price.

Layer	What it covers	Who bills it
Professional fee	Clinician work: interpretation for imaging, or performing the scope for endoscopy	Radiologist, cardiologist, or endoscopist
Technical / facility fee	Equipment, room, nursing and technologist time, supplies, recovery	Imaging center, office, ASC, or hospital
Anesthesia / sedation	Sedation or anesthesia care when used	Anesthesia group or the procedural team, depending on the model
Pathology	Lab processing and pathologist interpretation when tissue is taken	Pathology group or hospital lab

Two Medicare payment systems, one CPT code

Medicare does not pay the same way in every setting. That split is the anchor MyCarePrice shows, because commercial and cash prices often move in the same direction even when the dollar amounts differ.

Physician Fee Schedule (PFS)

The PFS pays clinicians for the service. For imaging it splits into a professional component (modifier 26) and a technical component (modifier TC). When one entity owns the equipment and provides the interpretation, it bills the global amount. In an office, Medicare pays a nonfacility amount that includes practice expense. In a facility, Medicare pays a lower facility professional amount because the facility bears the overhead and bills separately.

Our PFS anchors at launch come from the CMS Physician Fee Schedule for calendar year 2025, as published by the Medicare Administrative Contractor WPS GHA for Michigan Locality 01, effective January 1, 2025. The source name, year, and verification date are printed on every procedure page and in the checked-in data file. Locality-adjusted PFS amounts vary by geography. They are anchors, not your bill.

Hospital Outpatient Prospective Payment System (OPPS)

Hospitals are paid for the facility portion under OPPS. CMS groups services into Ambulatory Payment Classifications (APCs). Imaging services also map to composite APCs when multiple imaging services are billed together. For example, the CY2025 OPPS national unadjusted rate for the MRI without contrast composite (APC 8007) is $540.27, and for MRI with contrast composite (APC 8008) it is $854.83. The professional fee is billed separately on top of the OPPS amount.

That two-part payment - OPPS facility plus PFS professional - is structurally higher than a single PFS global payment for many imaging codes. It does not mean the hospital scan is performed differently. It means the payment system prices hospital overhead, standby capacity, and facility costs into the APC.

ASC payment system

Ambulatory surgery centers are paid under a separate ASC system for the facility portion of surgery and endoscopy. ASC facility rates are generally below hospital OPPS rates for the same procedure family. The endoscopist professional fee is the PFS facility amount. Anesthesia and pathology still bill separately when they apply.

Why the same scan costs more at a hospital

Three reasons account for most of the gap patients see:

1. Payment system. OPPS facility payment plus professional fee versus PFS global payment. The hospital route has two payments by design.
2. What is bundled. A hospital quote may include only the facility portion, with the radiologist billing separately weeks later. An imaging-center quote is more often a single global amount. Compare all-in to all-in.
3. Code differences. With contrast versus without, complete versus limited, screening versus diagnostic, two views versus one. A quote for the wrong CPT code will not match the bill. Confirm the exact code that was ordered.

What the Medicare anchor can and cannot do

The Medicare anchor tells you the relative order of magnitude and the direction of the facility lever. It does not tell you your cash price. Self-pay prices are set by each facility, are often negotiable before service, and depend on the exact code, setting, and what is bundled. MyCarePrice does not blend the Medicare anchor into a self-pay range and does not present hospital chargemaster list prices as what patients pay.

At launch, most procedure pages ship the verified Medicare anchor plus facility-type education and state plainly that self-pay ranges are not published yet. A self-pay range will be added only where it can be verified from a public source under Procedure Price Method v1.0.

How to shop without guessing

1. Get the exact CPT code and whether contrast, tomosynthesis, biopsy, or additional views are expected.
2. Ask each site the same question: "What is the all-in cash price for CPT [code] in [setting], including professional, facility, anesthesia, and pathology if they apply?"
3. Ask what changes the price on the day - for example, if a diagnostic colonoscopy becomes a biopsy colonoscopy.
4. Get the answer in writing before service, with the code, setting, and inclusions listed.
5. If you are uninsured or self-pay, ask for a Good Faith Estimate. See the playbook guide.

What this site does not do

MyCarePrice publishes prices only. We do not provide diagnosis, treatment recommendations, or advice about whether you should get a test or procedure. Those decisions belong with you and your clinician. Our job is to make the price conversation clearer before the service happens.

Next: try the Price Anchor Explorer, read a procedure page, or compare facility types.