Why you got a separate bill from the radiologist after your MRI, CT or X-ray

One scan, two jobs, two modifiers

Taking the pictures and reading them are different jobs done by different people, and the Medicare fee schedule prices them as separate pieces. Someone runs the scanner: the machine, the room, the technologist, the software and the supplies. A physician then studies the images and writes a report. The CMS relative value file tags the first job with modifier TC, for technical component, and the second with modifier 26, for professional component. A claim line with neither modifier is the global line, which bundles both jobs into one charge.

The file says what each piece contains. For imaging codes, it states that the total value units "for codes reported with a 26 modifier include values for physician work, practice expense, and malpractice expense," while codes "reported with a TC modifier include values for practice expense and malpractice expense only." The global line carries all three. Every equipment row in the file has 0.00 work units, so the whole equipment piece is the cost of running a scanner, and that is why it is the larger piece for every code on this page.

The radiologist's bill pays for the report. Chapter 13 of the Medicare Claims Processing Manual tells contractors to pay for the professional component of a radiology service furnished by a physician "in all settings," and it defines the interpretation of a diagnostic procedure as including a written report. That report went to the clinician who ordered the scan. The radiologist may never have met you: the same chapter describes teleradiology as radiology that does not require a face-to-face encounter with the patient, read through a telecommunications system. A group name you do not recognize, with a return address in another city, is an ordinary look for this bill.

A second statement is therefore not, by itself, a mistake or a double charge. Under the fee schedule the two pieces add back to the global amount, give or take a cent. The questions worth asking are narrower. Do the two statements belong to one scan or two? Does each come from a different billing entity? Do the amounts fit the table that follows?

Fourteen scans, split into the reading and the equipment

The amounts below are CY2026 Medicare fee schedule amounts for Michigan Locality 01 (Detroit), built from the October 2026 relative value file, the locality's three cost indices (work 1.000, practice expense 0.965, malpractice 1.686) and the $33.4009 conversion factor. Another locality moves every dollar figure. The last column repeats the reading's share with all three indices set to 1.000, to show how little the split depends on geography.

Source: CMS PFS RVU26D (PPRRVU2026_Oct_nonQPP, released 08/26/2026) and GPCI2026 (Addendum E, CY2026 final rule), Michigan Locality 01, nonfacility amounts, $33.4009 conversion factor. Each amount is rounded to the cent on its own, so 6 of the 14 reading and equipment pairs differ from the global amount by one cent. Computed and checked November 3, 2026. Medicare anchors, not your bill.

Show the numbers behind this figure

CPT	Equipment (TC)	Reading (26)	Global	Reading share
70450	$65.03	$40.21	$105.23	38.2 percent
70551	$123.61	$69.04	$192.65	35.8 percent
71046	$22.48	$10.16	$32.64	31.1 percent
71250	$80.50	$50.38	$130.87	38.5 percent
72100	$28.93	$10.80	$39.73	27.2 percent
72148	$119.42	$69.69	$189.10	36.9 percent
73560	$25.70	$8.16	$33.87	24.1 percent
73721	$137.14	$63.82	$200.97	31.8 percent
74177	$209.34	$85.62	$294.96	29.0 percent
76700	$74.61	$37.99	$112.60	33.7 percent
76856	$70.51	$33.01	$103.52	31.9 percent
77066	$107.17	$47.39	$154.56	30.7 percent
77067	$88.23	$35.67	$123.91	28.8 percent
77080	$29.25	$9.50	$38.75	24.5 percent

The reading is the smaller piece in all fourteen rows. Its share runs from 24.1 percent for CPT 73560, the knee X-ray ($8.16 of $33.87), to 38.5 percent for CPT 71250, the chest CT ($50.38 of $130.87). A larger scan does not mean a larger share. The abdomen and pelvis CT with contrast (74177) has the biggest reading in the table, $85.62, but only 29.0 percent of its $294.96 global amount, because its equipment piece, $209.34, is the biggest too.

The three plain X-rays are the small end. Their readings are $8.16 for the knee, $10.16 for the chest and $10.80 for the lumbar spine, so a radiologist's Medicare-priced bill for a plain film is a single-digit or low-double-digit amount. The three MRI codes cluster: readings of $69.04 (brain), $69.69 (lumbar spine) and $63.82 (knee), with the knee carrying the highest equipment piece of the three, $137.14, and the lowest reading. Mammography shows the effect of a code change on one bill: the screening code 77067 has a $35.67 reading and a $88.23 equipment piece, while the diagnostic code 77066 has a $47.39 reading, $11.72 more, and a $107.17 equipment piece, $18.94 more. If a statement shows 77066 where you expected 77067, both pieces sit on a different row of the table, and asking which code was billed and why is a billing question, not a medical one.

Building the 70551 numbers by hand

Every cell follows the formula in the file's documentation: work units times the work index, plus practice expense units times the practice expense index, plus malpractice units times the malpractice index, all multiplied by the conversion factor. For the brain MRI, the file lists the reading (70551-26) at 1.44 work, 0.51 practice expense and 0.08 malpractice units. In Detroit that is 1.44 x 1.000 = 1.44000, plus 0.51 x 0.965 = 0.49215, plus 0.08 x 1.686 = 0.13488, for 2.06703 adjusted units. Times $33.4009, that is $69.04.

The equipment piece (70551-TC) has 0.00 work, 3.80 practice expense and 0.02 malpractice units: 3.80 x 0.965 = 3.66700 plus 0.02 x 1.686 = 0.03372, for 3.70072 adjusted units, or $123.61. The global line has the units of both rows added (1.44, 4.31 and 0.10), 5.76775 adjusted units and $192.65. The two pieces, $69.04 plus $123.61, equal that to the cent. The reading's share is $69.04 divided by $192.65, which is 35.8 percent.

One more file detail applies to all 14 rows. Section 5102(b) of the Deficit Reduction Act of 2005 caps the fee schedule's technical component for certain imaging codes at the outpatient payment amount, and CMS publishes the capped amounts for each locality in a separate file called OPPSCAP. None of the 14 codes appears in the October 2026 OPPSCAP file, so the equipment amounts in the table are the uncapped formula results in every locality, not reduced figures. The comparison of hospital outpatient departments and imaging centers shows what the cap does to a code that is on the list.

The rule: one bill only when one entity does both jobs in one locality

Whether the global line is even available comes down to a paragraph in chapter 13 of the claims manual. It says that billing globally for services split into the two components "is only possible when the TC and the physician who provides the PC of the diagnostic service are furnished by the same physician or supplier entity and the PC and TC components are furnished within the same Medicare physician fee schedule payment locality." It adds that merely giving the reading the same place-of-service code as the equipment "does not permit global billing for any diagnostic procedure." There are three tests in that sentence: one entity, one locality, and both jobs actually done by it.

Fail any of the three and the reading must go out on its own claim with modifier 26. Seven patterns result.

Sources: Medicare Claims Processing Manual chapter 13, sections 20.1, 20.2.1, 20.2.2, 20.2.3 and 150 (Rev. 13150, issued 04-11-25). Checked November 3, 2026. Rules for Original Medicare; a private plan sets its own claim rules.

The first row comes from section 20.2.1, which says the contractor that pays physicians "may not pay for the technical component (TC) of radiology services furnished to hospital patients," and that radiology furnished to hospital outpatients is paid to the hospital under the outpatient payment system. Section 20.2.2 is its mirror image: the fee schedule does pay the technical component for patients who are not hospital patients and are scanned in a physician's office, a freestanding imaging center or another setting that is not part of a hospital. Section 20.2.3 covers the odd case of a leased hospital department treating someone who was never registered as a hospital outpatient, where both components are payable under the fee schedule.

The fifth row catches people. A company can own the scanner, employ the radiologist and still send two bills, because the global code requires that both components be furnished within one payment locality. Section 150 of the same chapter says that when the same entity furnishes both pieces but the interpretation took place in a different locality, the professional interpretation "must be separately billed with modifier -26 by the interpreting physician," with the interpreting physician's address and ZIP code on the claim. So an unfamiliar city on a reading bill can mean a remote reader employed by the same company that owns the scanner.

The same section carries the instruction that explains a code on the reading claim: as a general policy, the place-of-service code on the physician's claim for the reading "shall be the setting in which the beneficiary received the TC service." The manual's own example is an MRI at an outpatient hospital campus, read from the physician's office, where the reading claim uses place of service 22 (on-campus outpatient hospital). A later paragraph of section 150 names 19 as the code for an off-campus outpatient hospital. That code is the quickest way to read a radiologist's statement: a 22 or 19 says the radiologist's claim treats your scan as a hospital outpatient service, so a separate facility statement from the hospital should exist too.

Section 20.3 of the same chapter adds a limit for the fourth row: when a physician orders and bills for a test whose technical or professional component is performed by a physician who does not share a practice with the biller, the anti-markup payment limitation applies, and screening mammography is excluded from it. Whether an office bills for a reading it bought or the radiologist bills for it directly is the office's arrangement, and it is a fair question to put to the front desk. Private plans decide for themselves how their claims arrive, and no commercial price appears here. Whether your plan treats the scan as one claim or two shows on the explanation of benefits. The modifiers are the same labels, so the table is a map of the two pieces even when the amounts a plan pays for each are its own.

Why the reading costs the same $69.04 at the hospital and at the center

The documentation for the relative value file explains that the facility practice expense values "will be used for services performed in inpatient or outpatient hospital settings, emergency rooms, skilled nursing facilities, or ambulatory surgical centers," and the nonfacility values for all other settings. Look at the 14 codes with that in mind. In every one, the global row and the TC row carry an "NA" in the file's facility indicator, which the documentation defines as a procedure "rarely or never performed in the facility setting." The file prints a facility practice expense value on those two rows but flags them as not performed in the facility setting, which fits section 20.2.1 of the claims manual: for a patient of a hospital outpatient department paid under the outpatient payment system, the equipment piece is not paid on the fee schedule.

The 26 row has no such flag, and its facility and nonfacility practice expense units are identical in all 14 codes. The reading is $69.04 for 70551 whether the scanner sits in a hospital or a freestanding center, and $10.16 for the chest X-ray in either place. That gives a plain way to compare two quotes for the same scan. The reading is common to both settings, so any difference in the all-in price lives in the other piece: the hospital's facility payment on one side, the equipment amount or the global amount on the other. The guide to how facility fees work explains why that hospital layer exists, and the comparison of hospital outpatient and imaging center prices prints the hospital amounts for 11 scans without adding them to anything.

Under Original Medicare the hospital piece has its own cost-sharing rule. Medicare.gov says that if you get a test as a hospital outpatient, you "also pay the hospital a copayment that may be more than 20% of the Medicare-approved amount," and that in most cases the amount cannot be more than the Part A hospital stay deductible. The reading claim, for its part, follows the ordinary Part B rule of the deductible and then 20 percent of the approved amount. The two statements are therefore not interchangeable even when they arrive on the same day, and neither one can stand in for the other when you check them against an explanation of benefits.

What the same MRI looks like to you when it arrives whole or in pieces

The rows below price the brain MRI under Original Medicare with a freestanding center. They use the $283.00 Part B deductible for 2026, and assume the provider accepts the Medicare-approved amount. Row two and row three show the same scan after the center and the radiologist split it.

Source: CMS PFS RVU26D and GPCI2026, Michigan Locality 01, CY2026; 2026 Part B deductible of $283.00 from Medicare.gov. Computed and checked November 3, 2026. Medicare anchors, not your bill.

Splitting the scan does not change the total. Twenty percent of $192.65 is $38.53, and 20 percent of $123.61 plus 20 percent of $69.04 is $24.72 plus $13.81, also $38.53. What the split can change is which statement tells you what. The deductible is generally applied to claims in the order Medicare processes them, so two bills for one scan can show different percentages of their own approved amounts.

Here is that effect with a stated input, not a typical case: suppose $100.00 of the Part B deductible is still unmet before this scan. If the reading claim is processed first, the $69.04 reading is entirely absorbed by the deductible and you owe $69.04, which leaves $30.96 of the deductible. The equipment claim then asks $30.96 plus 20 percent of the remaining $92.65, which is $18.53, so $49.49. The total is $118.53. If the equipment claim is processed first, you owe $100.00 plus 20 percent of $23.61, which is $4.72, so $104.72, and the reading then costs $13.81. The total is again $118.53. The first order makes the reading look like a 100 percent bill, and the second makes it look like a 20 percent bill. Neither is an error, and the approved total is the same in both.

The Medicare Summary Notice shows the approved amount and what you may be billed for each claim. If you have a Medigap policy, a Medicare Advantage plan or private coverage, the numbers above change shape: a plan that charges a flat copayment can apply it to each claim or once to the scan, and the plan's benefit summary or member services line answers which. The guide to reading an explanation of benefits shows where each claim appears on that document. Larger outpatient services follow the same deductible and 20 percent logic in what Medicare patients pay for an outpatient procedure.

Rules that act mostly on the equipment piece

The relative value file marks 8 of the 14 codes with multiple procedure indicator 4: all the MRI, CT and ultrasound codes. The documentation says that when a procedure with indicator 4 is reported in the same session on the same day as another with the same family indicator, the equipment pieces are ranked by fee schedule amount, and "Pay 100% for the highest priced procedure, and 50% for each subsequent procedure." Each of those carries diagnostic imaging family value 88, which the file defines as "Subject to the reduction of the TC diagnostic imaging." The other 6 codes, the three X-rays, both mammograms and the bone density scan, carry indicator 0 and are not subject to the same-session rule.

A worked example makes the effect concrete. Two codes from the table show how the reduction works; the pairing is picked for the sum, not a typical order: an abdomen and pelvis CT with contrast (74177, equipment piece $209.34) and a chest CT without contrast (71250, equipment piece $80.50) in one session. The higher-priced equipment piece is paid at 100 percent, $209.34. The second is paid at 50 percent: $80.50 x 0.5 = $40.25. The two equipment pieces total $249.59 instead of $289.84, which is $40.25 less. The same documentation lists a 5 percent reduction for the professional component of diagnostic imaging, but its wording does not say which study carries it, so the reading amounts here are not adjusted. If a same-day pair arrives as two equipment lines, check whether the second one shows the reduction.

Three statutory adjustments apply to the equipment piece and sometimes appear as modifiers. Section 20.2.4 of the claims manual describes a reduction of 15 percent from 2017 on in the technical component for CT scans done on equipment that does not meet a national dose-management standard, flagged by modifier CT. Section 20.2.5 describes a 20 percent reduction for the technical component of X-rays taken using film, flagged by modifier FX. Section 20.2.6 describes a 7 percent reduction for 2018 through 2022 and a 10 percent reduction from 2023 on, for the technical component of X-rays taken with computed radiography, which section 1848(b)(9)(C) of the Act defines as cassette-based imaging that uses an imaging plate; the modifier is FY. None of the three is built into the table. Three of the fourteen rows are plain X-rays, and these are the rows where FX or FY can appear: the equipment piece is $22.48 for the chest (71046), $28.93 for the lumbar spine (72100) and $25.70 for the knee (73560). A 10 percent reduction would take about $2.25, $2.89 and $2.57 off those amounts, and a 20 percent film reduction about $4.50, $5.79 and $5.14, before any coinsurance. On a global line the reduction applies to the equipment portion only, not to the reading. If one of these modifiers shows up on an equipment claim, the approved amount will be lower than the table by design.

One protection sits on the equipment piece when the scan is a CT, MRI, nuclear medicine or PET scan outside a hospital. Medicare.gov says Medicare will pay for those only if the provider is accredited, and that if Medicare does not pay because the provider is not accredited, "the provider can't bill you for the test." An equipment claim denied for that reason is the provider's loss under that rule, not a balance to forward to you. The reading claim is a separate claim, and its status is a separate question.

Out-of-network readers after an in-network scan

For people with group or individual health insurance, as opposed to Original Medicare, the radiologist's network status can decide the bill. Under 45 CFR 149.420(a), a nonparticipating provider who furnishes covered non-emergency items or services at a participating health care facility must not bill the patient more than the in-network cost-sharing amount for the visit. Paragraph (b)(1) lists the ancillary services for which the notice-and-consent exception never applies, and it names "items and services related to emergency medicine, anesthesiology, pathology, radiology, and neonatology" and "diagnostic services, including radiology and laboratory services." A form signed at check-in does not change the limit for a reading.

Two definitions in 45 CFR 149.30 decide who is inside the rule. The first is the list of health care facilities for non-emergency services: a hospital, a hospital outpatient department, a critical access hospital and an ambulatory surgical center. A freestanding imaging center is not on it. The second is the definition of a visit, which includes "imaging services, laboratory services, and preoperative and postoperative services, regardless of whether the provider furnishing such items or services is at the facility." That second definition is why a reading done by a remote radiologist for a scan at a hospital outpatient department can still fall under the protection. The outcome for a scan at a freestanding center depends on state law, which this page does not cover.

If the scan was ordered during an emergency department visit, 45 CFR 149.410(a)(2) applies a similar limit to nonparticipating providers who furnish emergency services at the hospital's emergency department, and the guide to emergency room visit levels shows how that visit splits into a facility line and a physician line. The step-by-step version of the insured-patient rules is in the guide to balance billing under the No Surprises Act, and the same logic for the pathologist who reads tissue is in the pathology bill guide. Anesthesia has its own version, covered in how an anesthesia bill is calculated.

The same scans in four places: the dollars move more than the split

The share does not stay put, but it drifts less than the dollars do. The table shows two codes from the main table at four sets of cost indices: Detroit, the national indices, Manhattan and Mississippi.

Source: CMS PFS RVU26D and GPCI2026 (Addendum E, CY2026 final rule), $33.4009 conversion factor. Indices: Detroit 1.000 / 0.965 / 1.686, Manhattan 1.064 / 1.162 / 1.586, Mississippi 1.000 / 0.861 / 0.739 (work / practice expense / malpractice). Computed and checked November 3, 2026. Medicare anchors, not your bill.

The brain MRI global amount is $223.75 in Manhattan and $174.51 in Mississippi, a spread of $49.24. The reading alone varies by $10.47, from $64.74 to $75.21. The reading's share of the global amount, meanwhile, stays between 33.6 and 37.1 percent across the four columns. The driver is the practice expense index. The equipment piece is almost all practice expense, so it rises and falls with that index, while the reading is mostly work units, whose index sits at or near 1.000. Where the practice expense index is low, as in Mississippi at 0.861, the reading takes a larger share; where it is high, as in Manhattan at 1.162, a smaller one. Detroit's 0.965 is under 1.000, which is why its share runs about one point above the national share in every row of the main table.

What to say to the two billing offices

Two statements for one scan call for two short conversations, each aimed at the entity that sent the bill. For the one that looks like the equipment piece, which usually carries the hospital's or the center's name: "For my scan on this date, CPT [the code on the order], did you bill the equipment piece only, with modifier TC, or the global code? Is the radiologist's reading included in your charge, or billed by someone else?" For the one that looks like the reading, usually from a group: "Please send an itemized statement showing the CPT code, modifier 26, the place-of-service code, the date of service and the billing provider's name. Which facility did you read the images for?"

Then compare the two answers. They fit together when one office billed the equipment piece (or the hospital's facility payment) and the other billed the reading with modifier 26. They do not fit when both claim the global code, or when the amounts claimed for one scan sum to well above the table's global amount for that code with no modifier or multiple-study rule explaining the gap. Put the codes, dates and amounts from both statements side by side the way the itemized-bill check describes, and write down who said what. If you are paying yourself rather than through insurance, the cash-price guide has the wording for asking each office for its price in writing, and the Good Faith Estimate guide explains when a provider owes you a written estimate.

One sentence to each office prevents a mix-up: ask the scanning site what its quote includes, and ask the radiologist's office what the reading charge is for the exact CPT code. A hospital quote that says it covers the "MRI" can mean the facility piece alone. A center quote that says "includes the radiologist" is a global quote, and the procedure pages print the reading and equipment pieces for the scan codes this site covers.

Radiologist bill questions

Fee files, manuals and rules behind the radiology figures

• CMS, Physician Fee Schedule relative value file RVU26D (October 2026 release, PPRRVU2026_Oct_nonQPP released 08/26/2026, the newest 2026 file on CMS's relative value file index), with the CY2026 GPCI file and the OPPSCAP file in the same download: work, practice expense and malpractice units for each code and for its -26 and TC rows, facility and nonfacility indicators, multiple procedure indicator 4, the PC/TC indicator definitions, the payment formula, the DRA 5102(b) cap, and the $33.4009 conversion factor. Computed and checked November 3, 2026.
• U.S. Code, 42 U.S.C. 1395w-4(b)(9) (Social Security Act section 1848(b)(9)), the 20 percent film and 7 and 10 percent computed radiography reductions to the technical component. Checked November 3, 2026.
• CMS, Medicare Claims Processing Manual, chapter 13, Radiology Services and Other Diagnostic Procedures (Rev. 13150, issued 04-11-25), sections 20.1 (professional component), 20.2.1 to 20.2.3 (technical component for hospital patients, patients outside hospitals and leased departments), 20.2.4 to 20.2.6 (CT modifier, film X-ray and computed radiography reductions) and 150 (place of service, global billing and separate billing of the interpretation). Checked November 3, 2026.
• eCFR, 45 CFR 149.420 (non-emergency services by nonparticipating providers at participating facilities), 45 CFR 149.410 (emergency services) and 45 CFR 149.30 (definitions of health care facility and visit). Version dated October 27, 2026, checked November 3, 2026.
• Medicare.gov, Diagnostic non-laboratory tests: 20 percent after the Part B deductible, the hospital outpatient copayment, and the accreditation condition for advanced imaging outside a hospital. Checked November 3, 2026.
• Medicare.gov, Medicare costs, 2026 Part B deductible of $283.00. Checked November 3, 2026.

General billing information, not medical, legal or insurance advice. Medicare anchors are not your bill, and a radiologist's or imaging center's own charges and a plan's allowed amounts can differ from them. Confirm your price in writing before service.