What do insurers pay for CPT 97167?

Across commercial payer filings nationally, the observed median contracted rate for CPT 97167 (OT evaluation, high complexity) is $102.45, with a 25th-to-90th percentile range of $82.99 to $235.40, from 2,349,969 published rate observations. Modeled from public filings, not guaranteed.

What is the range of rates for CPT 97167?

The observed distribution runs from a 25th percentile of $82.99 to a 90th percentile of $235.40, with a median of $102.45. This is a national spread across payers; local, payer-specific rates vary.

How does the commercial rate for CPT 97167 compare to Medicare?

The observed commercial median of $102.45 is about 102% of Medicare's national non-facility rate of $100.54 for CPT 97167.

Where does this CPT 97167 rate data come from?

From the machine-readable files insurers are federally required to publish under the Transparency in Coverage Rule (45 CFR §147.212), joined to the CMS Medicare Physician Fee Schedule. No patient data is used.

Reddenda · Rate Intelligence · National

97167: OT evaluation, high complexity

What commercial payers pay · observed distribution across payer filings · 2,349,969 rate observations

$102.45 observed median. Across commercial payer filings nationally, CPT 97167 (OT evaluation, high complexity) shows an observed contracted-rate distribution with a median of $102.45 (25th percentile $82.99, 75th $148, 90th $235.40), from 2,349,969 published rate observations, about 102% of Medicare. As of 2026-07-24. Documented from public Transparency-in-Coverage filings, modeled and not guaranteed.

National rate distribution · 2,349,969 published rate observations

25th pct

$82.99

Median

$102.45

75th pct

$148

90th pct

$235.40

25th pct$82.99

Median$102.45

75th pct$148

90th pct$235.40

Medicare$100.54

Basis: national, across payer filings Source: federal Transparency-in-Coverage filings As of: 2026-07-24

The national median commercial rate observed for CPT 97167 (OT evaluation, high complexity) is $102.45, from 2,349,969 published rate records across payers.Source: the federal Transparency in Coverage Rule (45 CFR §147.212), which compels payers to publish these rates
The observed spread runs from a 25th percentile of $82.99 to a 90th percentile of $235.40: a 184% difference between the low and high of the distribution for the same code.Source: 45 CFR §147.212 (Transparency in Coverage)
Medicare's national non-facility rate for CPT 97167 is $100.54, so the observed commercial median of $102.45 is about 102% of Medicare.Source: CMS Medicare Physician Fee Schedule
This is a national distribution across payers, not a local or payer-specific benchmark. What a specific provider is actually paid depends on its own contracts and local market; a RateScore measures that against local peers.Source: Reddenda methodology
A federal No Surprises Act arbitrator may weigh up to four plan years of a provider's own contracted rate history and local market share when resolving a payment dispute over this code.Source: 45 CFR §149.510(c)(4)(iii)(B) (No Surprises Act IDR)

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Documented reimbursement opportunity, modeled from published rates and never a guaranteed outcome.

Observed distribution across payer filings nationally, modeled from public rates and never guaranteed. This is not a local peer median or a RateScore: those measure a specific provider against its local peers and its own payers. Basis: CMS-descriptor CPT 97167 across indexed commercial payer files. Federal citation for the underlying obligation: 45 CFR §147.212. As of 2026-07-24; page generated 2026-07-24 17:50 UTC.