How much does Medicare pay for CPT 97166?

Medicare allowed an average of $101.22 per service and paid $76.63 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $183.73, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 97166?

Evaluation for occupational therapy, typically 45 minutes. It was billed 141,320 times to 125,991 Medicare beneficiaries by 4,494 providers in 2024.

Does 97166 pay differently in an office than a hospital?

Yes. The allowed amount averaged $101.22 in an office setting and $102.64 in a facility. The office rate is generally higher because the practice supplies the room, staff and equipment out of that single payment; in a hospital those are billed separately by the facility.

Which specialty bills 97166 most?

Occupational Therapist in Private Practice, with 135,838 services from 4,428 clinicians. Next are General Practice, Family Practice, Orthopedic Surgery.

CPT 97166

Evaluation for occupational therapy, typically 45 minutes

$101.22Medicare-allowed amount per service, averaged across 141,320 services

Providers submitted

$183.73

Asking price, not received

Medicare allowed

$101.22

The fee schedule figure

Medicare paid

$76.63

Balance is patient coinsurance

Providers submitted an average of $183.73 for this code and Medicare allowed $101.22 — 1.8× less. That gap is normal and means nothing on its own: Medicare pays its fee schedule regardless of what is billed, so the submitted figure describes a hospital chargemaster, not a price anyone paid. Of the allowed amount Medicare paid $76.63 (76%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $101.22
Hospital / facility: $102.64

The facility rate is higher for this code, which is unusual and generally means the service depends on equipment or staffing a hospital carries. 141,121 services were billed in an office setting and 199 in a facility.

Services: 141,320
Beneficiaries: 125,991
Providers billing it: 4,494
Total allowed: $14,304,410

What Medicare pays for CPT 97166

Across 141,320 services billed by 4,494 providers to 125,991 beneficiaries, Medicare allowed an average of $101.22 per service. The allowed amount is the figure that matters: it is what Medicare and the patient together owe, set by the fee schedule and adjusted for local practice costs. What a provider chose to submit has no bearing on it.

Who bills 97166

Specialty	Services	Beneficiaries	Avg allowed	Providers
Occupational Therapist in Private Practice	135,838	123,479	$101.14	4,428
General Practice	2,930	591	$105.42	3
Family Practice	696	191	$110.00	1
Orthopedic Surgery	541	523	$97.77	15
Hand Surgery	353	351	$97.72	12
Neurology	306	261	$100.21	9
Physical Therapist in Private Practice	258	231	$97.29	12
Physical Medicine and Rehabilitation	162	140	$99.05	4
Nurse Practitioner	48	46	$86.64	2
Vascular Surgery	46	43	$91.77	1
Optometry	38	38	$102.00	1
Physician Assistant	24	20	$78.08	1
Emergency Medicine	20	20	$96.46	1
General Surgery	18	15	$92.39	1
Gastroenterology	17	17	$95.62	1

97166 reimbursement by state

Two different numbers. Allowed is what Medicare actually allowed in that state, which includes the local practice-cost adjustment. Standardized strips that geographic adjustment out of the payment, so it is the column to use when comparing states — a difference there reflects how the code was billed, not what it costs to run a practice locally.

State	Services	Allowed	Standardized pmt	Providers
New York	19,177	$110.55	$75.94	503
New Jersey	12,899	$107.41	$75.26	432
California	12,814	$107.19	$75.53	265
Florida	11,581	$98.24	$75.57	329
Pennsylvania	7,361	$99.05	$74.68	238
Illinois	6,162	$98.62	$75.33	225
Maryland	4,448	$103.42	$74.82	145
Texas	4,437	$97.77	$75.56	150
Indiana	3,488	$94.12	$74.61	114
Georgia	3,347	$96.84	$75.24	116
North Carolina	3,195	$94.74	$75.42	117
Ohio	3,106	$95.77	$75.75	98
Virginia	3,087	$101.10	$75.04	107
Iowa	2,977	$95.22	$73.30	69
Massachusetts	2,642	$105.18	$74.96	92
Missouri	2,576	$95.42	$74.17	92
Tennessee	2,452	$93.06	$75.35	97
Minnesota	2,417	$99.02	$74.13	98
South Carolina	2,324	$94.62	$75.80	86
Arizona	2,206	$96.82	$75.52	71
Washington	2,125	$104.17	$74.67	90
Colorado	2,054	$101.15	$74.40	85
Wisconsin	1,949	$96.13	$74.31	95
Mississippi	1,866	$91.64	$74.49	59
Michigan	1,780	$97.96	$75.17	82
Connecticut	1,725	$105.30	$74.21	60
Louisiana	1,676	$92.08	$76.04	54
Kentucky	1,642	$93.17	$75.80	57
Alabama	1,567	$91.98	$75.55	37
Utah	1,144	$95.29	$75.41	42
Nevada	1,013	$98.20	$75.17	33
Kansas	985	$94.03	$74.91	31
Oklahoma	952	$91.95	$75.35	31
Oregon	921	$99.77	$74.49	30
Arkansas	824	$91.16	$75.56	32
Delaware	823	$100.18	$71.69	31
Nebraska	791	$93.95	$73.94	33
Wyoming	656	$98.15	$72.64	21
Montana	596	$98.81	$74.13	19
Maine	568	$98.99	$73.50	25
New Hampshire	457	$100.38	$75.10	16
West Virginia	433	$93.17	$75.28	14
South Dakota	421	$98.74	$73.09	15
New Mexico	326	$98.45	$74.42	10
Rhode Island	314	$104.26	$71.13	12
District of Columbia	305	$111.55	$73.58	7
North Dakota	286	$99.09	$72.98	11
Hawaii	129	$95.20	$71.25	4
Alaska	76	$119.98	$65.71	4
U.S. Virgin Islands	72	$98.77	$75.34	2
Vermont	50	$100.01	$76.43	3
Idaho	39	$94.88	$76.02	3
XX	38	$92.60	$78.10	1
AE	21	$110.51	$72.53	1

Related codes

97110Therapy procedure$22.78
97112Therapy procedure to re-educate brain-to-nerve-to-muscle function$27.06
97140Therapy procedure$20.62
97116Therapy procedure for walking training$21.87
97150Therapy procedure in a group setting$13.60
97161Evaluation for physical therapy$99.49
97162Evaluation for physical therapy$99.21
97113Therapy procedure$27.67
97130Therapy procedure for a range of mental processes$21.18
97164Re-evaluation for physical therapy$68.54
97124Therapy procedure$25.23
97129Therapy procedure for a range of mental processes$21.82

Billing this code is not the same as earning it

An allowed amount is revenue to a practice, not income to a clinician. It funds staff, premises, equipment and supplies before anyone is paid. What clinicians actually earn is published separately by the Department of Labor, and what industry pays them is published separately again by CMS — this site carries both.

What doctors are paid →·Look up a clinician →·All procedure codes →

Where this comes from. CMS Medicare Physician & Other Practitioners, by Provider and Service, 2024. It covers fee-for-service Original Medicare Part B only — not Medicare Advantage, not Medicaid, and not commercial insurance, which typically pays more for the same code.

How it is averaged. CMS publishes one average per provider per code. Every figure here is re-weighted by the number of services, so a clinician who billed the code 4,000 times counts 4,000 times more than one who billed it twice. CMS also suppresses any provider-code pair with fewer than 11 beneficiaries, so low-volume practice is missing from these totals by design.