Hospital outpatient department: OPPS facility fee plus professional fee
A hospital outpatient department bills the facility portion under the Hospital Outpatient Prospective Payment System and the clinician bills the professional fee separately under the Physician Fee Schedule. That two-part structure is the main reason the same CPT code costs more here.
Confirm your price in writing before service. Ask whether the quote is facility-only or all-in.
- Setting
- Imaging, lab, and procedure departments located in or owned by a hospital, including off-campus hospital departments
- Payment system
- OPPS (APC-based facility payment) + Physician Fee Schedule professional fee
- Facility fee
- Yes - separate OPPS facility payment to the hospital
Under OPPS, CMS groups the facility service into an Ambulatory Payment Classification. A single imaging study billed alone is paid through its own single-service APC: in the CY2026 October 2026 Addendum B, brain, spine and knee MRI without contrast map to APC 5523 at $243.77, and head CT, chest CT without contrast and the abdominal and pelvic ultrasounds map to APC 5522 at $106.81 (national unadjusted). Composite APCs, such as APC 8007 for MRI without contrast at $537.85, apply only when several qualifying studies are billed on one claim (multi-study only, national unadjusted). The professional fee is not inside any of those amounts. It bills separately.
Hospital outpatient departments carry standby capacity, emergency coverage, and facility overhead that CMS prices into OPPS rates. A cash quote from a hospital may name only the facility portion. Ask whether the radiologist, cardiologist, or endoscopist fee is included, and ask the same question about anesthesia and pathology for endoscopy.
Use the Medicare anchors on this site to judge order of magnitude, then get the hospital cash price for your exact CPT code in writing. Ask what the same code would cost if performed in an imaging center, ASC, or office when your clinician offers that choice.
Hospital facility anchors on record, with the professional side
Every procedure on this site that carries an OPPS facility anchor, shown as the single-service APC payment for that code billed alone (national unadjusted), next to the professional fee that a hospital visit adds on top. Composite rates for multi-study claims are on each procedure page.
| Procedure | CPT | OPPS facility anchor | Professional fee (26 or facility PFS) |
|---|---|---|---|
| MRI Without Contrast | 70551 | $243.77 (APC 5523) | $69.04 |
| MRI With Contrast | 70553 | $356.43 (APC 5572) | $107.27 |
| CT Abdomen and Pelvis | 74177 | $356.43 (APC 5572) | $85.62 |
| CT Head | 70450 | $106.81 (APC 5522) | $40.21 |
| Ultrasound Abdomen | 76700 | $106.81 (APC 5522) | $37.99 |
| MRI Lumbar Spine | 72148 | $243.77 (APC 5523) | $69.69 |
| MRI Knee | 73721 | $243.77 (APC 5523) | $63.82 |
| CT Chest | 71250 | $106.81 (APC 5522) | $50.38 |
| CT Abdomen and Pelvis Without Contrast | 74176 | $243.77 (APC 5523) | $81.19 |
| Ultrasound Pelvis | 76856 | $106.81 (APC 5522) | $33.01 |
| Ultrasound Transvaginal | 76830 | $106.81 (APC 5522) | $33.01 |
| Ultrasound Abdomen Limited | 76705 | $106.81 (APC 5522) | $27.83 |
| DXA Bone Density | 77080 | $106.81 (APC 5522) | $9.50 |
| Ultrasound Thyroid and Neck | 76536 | $106.81 (APC 5522) | $26.83 |
| X-Ray Lumbar Spine | 72100 | $106.81 (APC 5522) | $10.80 |
| Echocardiogram Limited | 93308 | $243.77 (APC 5523) | $24.94 |
| Sleep Study (Polysomnography) | 95810 | $877.34 (APC 5724) | $120.89 |
| Colonoscopy With Biopsy | 45380 | $1,222.56 (APC 5312) | $185.64 |
| Upper Endoscopy (EGD) With Biopsy | 43239 | $926.63 (APC 5301) | $128.48 |
| Carpal Tunnel Release | 64721 | $1,995.02 (APC 5431) | $437.89 |
| Cataract Surgery | 66984 | $2,357.81 (APC 5491) | $467.80 |
| Knee Arthroscopy (Meniscectomy) | 29881 | $3,342.87 (APC 5113) | $539.38 |
Medicare anchors verified 2026-10-18: fee schedule amounts for Michigan Locality 01, hospital amounts national unadjusted. Not cash prices. The general explanation of facility fees and the four questions that work in any setting are on the facility types overview.
Reading a hospital outpatient quote
A hospital estimate often arrives as a single facility figure built from the hospital chargemaster, with the physician bills left to follow. Ask the hospital to say in writing which professional groups will bill you, for example radiology, anesthesia, or pathology, and whether those groups are in the same network as the hospital.
For imaging, ask whether the estimate assumes a composite payment. A composite applies when several qualifying scans are billed on one claim; a single scan is paid at a single-service rate. The procedure pages on this site list both where they differ.
Questions for this setting
- Is this estimate the facility charge only, and which physician groups will bill separately?
- Is the department on the main campus or an off-campus location that still bills as the hospital?
- Does the estimate assume one scan, or several scans that would be paid as a composite?
- If the visit is booked as observation or an emergency visit instead, how does the bill change?