CPT Codes & Medicare Rates: The Complete Patient's Guide (2026)

CPT codes (Current Procedural Terminology) are the universal 5-digit billing codes used by hospitals, physicians, and labs to report every medical service. Your bill lists these codes to tell insurance companies — and Medicare — exactly what was done and at what charge. This guide explains how CPT codes work, lists Medicare's published reimbursement rates for the 50 most common procedures, and shows you how to spot overbilling.

What Are CPT Codes?

CPT codes were created and are maintained by the American Medical Association (AMA). Every covered service — from a blood test ($12 at Medicare rates) to a knee replacement ($1,572) — has a code. When a hospital or doctor submits a claim to your insurance, they list CPT codes to describe each service.

The codes fall into three categories:

• Category I — The main codes covering procedures, services, and tests (the ones you'll see on most bills)
• Category II — Tracking codes for performance measurement (usually not billed to patients)
• Category III — Temporary codes for new and experimental technology

Each year, CMS publishes the Medicare Physician Fee Schedule — a table of what Medicare will pay for every CPT code in every geographic region. This is the benchmark BillKarma uses to flag overcharges.

Medicare's Published Rates for the 50 Most Common CPT Codes

The table below shows national average Medicare facility rates (what Medicare pays the hospital or facility). These rates are published by CMS and updated annually. Your actual bill may be higher — sometimes much higher.

Rates are national averages. Local rates vary by geographic area. Source: CMS 2026 Medicare Physician Fee Schedule.

ER Visit CPT Codes (99281–99285)

Emergency room visits are billed using one of five "evaluation and management" (E/M) codes based on complexity. Level 5 (99285) is the highest and most expensive. You should be billed at the level matching your actual condition — not automatically at Level 4 or 5, which hospitals sometimes do to maximize revenue.

• CPT 99281: ER Visit – Level 1 — Medicare rate $29
• CPT 99282: ER Visit – Level 2 — Medicare rate $61
• CPT 99283: ER Visit – Level 3 — Medicare rate $116
• CPT 99284: ER Visit – Level 4 — Medicare rate $183
• CPT 99285: ER Visit – Level 5 — Medicare rate $266

Office Visit CPT Codes (99212–99215)

Outpatient office visits are also billed on a complexity scale. A routine annual physical should rarely be coded as a Level 5 (99215) visit. If you see a high-level code on a short appointment, request an explanation.

• CPT 99212: Office Visit – Level 2 — Medicare rate $47
• CPT 99213: Office Visit – Level 3 — Medicare rate $82
• CPT 99214: Office Visit – Level 4 — Medicare rate $118
• CPT 99215: Office Visit – Level 5 — Medicare rate $172
• CPT 99213: Annual Wellness Visit — Medicare rate $82

Imaging CPT Codes (MRI, CT, X-Ray)

Imaging is one of the most widely overbilled categories. The same MRI can cost $200 at a freestanding imaging center and $3,000+ at a hospital — the Medicare rate is the same for both. The difference is entirely facility markup.

• CPT 70553: MRI Brain (With Contrast) — Medicare rate $268
• CPT 72148: MRI Lumbar Spine — Medicare rate $200
• CPT 74177: CT Abdomen/Pelvis (With Contrast) — Medicare rate $233
• CPT 74178: CT Abdomen/Pelvis (W/WO Contrast) — Medicare rate $272
• CPT 71046: Chest X-Ray (2 Views) — Medicare rate $29
• CPT 66984: Cataract Surgery with Lens Implant — Medicare rate $718

Lab Test CPT Codes

Lab tests have some of the lowest Medicare rates of any service — most panels cost under $20 at Medicare rates. Charges of $100–$400 for basic panels are common and worth disputing.

• CPT 80048: Basic Metabolic Panel (BMP) — Medicare rate $14
• CPT 80053: Comprehensive Metabolic Panel (CMP) — Medicare rate $18
• CPT 85025: Complete Blood Count (CBC) — Medicare rate $12
• CPT 84443: TSH (Thyroid) Test — Medicare rate $26

Surgery CPT Codes

Surgical procedures have the highest Medicare rates and also the highest potential for overbilling. Common issues include unbundling (billing separately for components of a single surgery), assistant surgeon charges, and facility fees layered on top of the surgeon's bill.

• CPT 27447: Total Knee Replacement — Medicare rate $1,572
• CPT 27130: Total Hip Replacement — Medicare rate $1,531
• CPT 29827: Shoulder Arthroscopy – Rotator Cuff Repair — Medicare rate $678
• CPT 29881: Knee Arthroscopy – Meniscectomy — Medicare rate $421
• CPT 47562: Laparoscopic Cholecystectomy (Gallbladder) — Medicare rate $715
• CPT 49505: Inguinal Hernia Repair — Medicare rate $424
• CPT 44970: Appendectomy – Laparoscopic — Medicare rate $734
• CPT 44950: Appendectomy – Open — Medicare rate $589
• CPT 63047: Lumbar Laminectomy — Medicare rate $1,238
• CPT 22612: Lumbar Spinal Fusion — Medicare rate $2,174
• CPT 66984: Cataract Surgery with Lens Implant — Medicare rate $718
• CPT 19307: Modified Radical Mastectomy — Medicare rate $1,456

Cardiac CPT Codes

• CPT 92928: Coronary Stent Placement — Medicare rate $2,109
• CPT 93000: EKG/ECG with Interpretation — Medicare rate $18
• CPT 93306: Echocardiogram (Complete) — Medicare rate $183

Physical and Mental Health Therapy CPT Codes

Therapy visits are commonly billed without itemized CPT codes on patient statements. Ask your provider for a superbill that lists the exact codes — this is your right under HIPAA.

• CPT 97110: PT – Therapeutic Exercise — Medicare rate $28
• CPT 97530: PT – Therapeutic Activities — Medicare rate $28
• CPT 90834: Psychotherapy – 45 Minutes — Medicare rate $75
• CPT 90837: Psychotherapy – 60 Minutes — Medicare rate $99
• CPT 90847: Family Therapy with Patient Present — Medicare rate $95

Obstetrics CPT Codes

Maternity care is often billed as a "global package" (all prenatal visits + delivery + postpartum). The global package codes (59400, 59510) are often underpriced by insurers while hospitals add facility fees separately — resulting in surprise bills.

• CPT 59400: Vaginal Delivery – Global OB Package — Medicare rate $2,291
• CPT 59510: Cesarean Delivery – Global OB Package — Medicare rate $2,698

How to Use CPT Codes to Audit Your Bill

1. Request your itemized bill. Every hospital must provide one. Call the billing department and ask for an itemized statement listing each CPT code and charge.
2. Look up the Medicare rate. Find your CPT code in the table above or use BillKarma's Medicare rate calculator.
3. Calculate the markup. Divide your charge by the Medicare rate. A 3× markup is typical. Above 5× is often disputable.
4. Check for common errors:
   • Duplicate charges (same CPT code billed twice)
   • Upcoding (a routine level-3 visit billed as level-5)
   • Unbundling (components of a packaged procedure billed separately)
   • Services you didn't receive
5. Send a dispute letter. Use our free dispute letter template to formally challenge incorrect charges.

Common CPT Code Billing Errors to Watch For

Upcoding: A hospital bills CPT 99285 (Level 5 ER visit, $266 Medicare rate) when your visit was actually a Level 3 ($116). This adds $150+ to Medicare's payment — and multiples of that to what you owe.

Unbundling: A colonoscopy with biopsy (CPT 45380, $257 Medicare rate) should be billed as a single code. Some facilities bill separately for the scope, the biopsy specimen, and the pathology — multiplying what you owe.

Facility fees added to already-included codes: Some hospital outpatient departments add a facility fee on top of a CPT code that already includes facility overhead. This is improper double billing.

Frequently Asked Questions

How do I find the CPT code on my bill?

Look for a column labeled "Procedure Code," "CPT," or "Service Code" on your Explanation of Benefits (EOB) or itemized hospital bill. If you only received a summary statement, call the billing department and specifically ask for an itemized bill with CPT codes.

Can a hospital charge any amount for a CPT code?

Technically yes — hospitals set their own prices ("chargemaster" rates). But if your insurer has a negotiated contract, you pay the contracted rate. If you're uninsured, hospitals must offer a good-faith estimate before non-emergency services under the No Surprises Act.

What does "facility rate" vs "non-facility rate" mean?

Medicare publishes two rates per CPT code: a facility rate (for services provided in a hospital or outpatient department) and a non-facility rate (for office-based services). Hospital outpatient departments typically charge more than independent physician offices for identical services.

What is the 3× rule for CPT code billing?

A common patient-advocacy benchmark: if a hospital charges more than 3× the Medicare rate for a CPT code, the overcharge is worth disputing. Some hospitals charge 10×–20× Medicare rates for common procedures.

Do CPT codes change each year?

Yes. The AMA updates the CPT code set annually (effective January 1). New codes are added, others are deleted, and descriptions change. Medicare rates are also updated annually via the Medicare Physician Fee Schedule Final Rule, published each November.