Evaluation For Occupational Therapy, Typically 30 Minutes
What Medicare pays for 97165, what providers bill, and how the price varies across 53 states, drawn from CMS 2023 claims data.
97165 · the short answer
For evaluation for occupational therapy, typically 30 minutes, Medicare pays about $76.00 while providers bill $204.28 on average, a 2.7× markup, one of the smaller markups in the catalog. State-level Medicare rates range 46% from lowest to highest.
- Medicare pays
- $76.00
- Providers bill
- $204.28
- Markup
- 2.7×
- Markup percentile
- 9th
Medicare amounts are CMS-published; markup = average submitted charge ÷ average Medicare payment.
Price Range Across States
What You Might Pay
Estimated using RAND 2024 commercial-to-Medicare ratios. Actual prices vary by insurer, plan, and facility.
How we estimate these prices
These estimates are based on the RAND Hospital Price Transparency Study (4th Edition, 2024), which found that commercial insurance prices average 224% of Medicare rates nationally. We apply category-specific ratios: Medicine procedures average 2.15x Medicare rates. Cash/self-pay estimates blend typical cash discounts (55% of billed charges) with Medicare-based estimates (150% of allowed amounts). These are statistical estimates, not quotes. Contact your insurer or provider for actual costs.
Where this markup sits nationally
Markup (billed ÷ Medicare) across 8,901 procedures with a meaningful Medicare rate
3 more affordable than 9% of 8,901 procedures
Each bar is a band; taller bars hold more procedures. The dashed line + filled bar mark this entry. Hover or tap any bar for its full count, share, and where it sits relative to this entry.
Source CMS Medicare Physician & Other Practitioners · 2023
Prices by State
| State | Medicare Payment | Billed Charge |
|---|---|---|
| Alaska | $94.62 | $218.59 |
| District of Columbia | $84.94 | $253.23 |
| New York | $83.86 | $186.42 |
| New Jersey | $82.12 | $198.91 |
| California | $81.80 | $211.56 |
| Connecticut | $81.42 | $193.63 |
| Maryland | $80.69 | $217.75 |
| Massachusetts | $79.37 | $194.45 |
| Colorado | $77.15 | $226.52 |
| Rhode Island | $76.76 | $190.45 |
| Delaware | $76.71 | $340.96 |
| Virginia | $76.67 | $198.29 |
| Washington | $76.11 | $207.78 |
| Pennsylvania | $75.75 | $226.27 |
| Illinois | $75.68 | $198.96 |
| Hawaii | $75.63 | $152.54 |
| Nevada | $74.95 | $209.81 |
| Minnesota | $74.49 | $276.52 |
| Vermont | $74.33 | $122.75 |
| Montana | $73.97 | $173.34 |
| Florida | $73.62 | $220.04 |
| Oregon | $73.53 | $224.97 |
| Michigan | $73.50 | $189.98 |
| Texas | $73.27 | $205.89 |
| Wyoming | $73.16 | $165.35 |
| North Dakota | $73.13 | $222.32 |
| U.S. Virgin Islands | $73.10 | $679.64 |
| South Dakota | $72.95 | $177.30 |
| Arizona | $72.85 | $234.16 |
| New Hampshire | $72.83 | $198.12 |
| Georgia | $72.61 | $204.23 |
| North Carolina | $72.21 | $199.17 |
| Utah | $72.09 | $168.08 |
| Ohio | $71.83 | $171.80 |
| South Carolina | $71.67 | $184.68 |
| New Mexico | $71.29 | $153.19 |
| Indiana | $71.18 | $202.30 |
| Missouri | $71.17 | $183.80 |
| Wisconsin | $71.05 | $235.73 |
| Iowa | $70.96 | $203.08 |
| Kansas | $70.73 | $213.04 |
| Tennessee | $70.67 | $203.23 |
| Louisiana | $70.61 | $173.65 |
| Alabama | $70.57 | $179.25 |
| Nebraska | $70.01 | $179.33 |
| Idaho | $69.87 | $130.05 |
| Oklahoma | $69.76 | $163.32 |
| Kentucky | $69.53 | $172.16 |
| Maine | $69.04 | $180.66 |
| Arkansas | $68.99 | $176.74 |
| Puerto Rico | $68.60 | $87.50 |
| Mississippi | $68.39 | $182.43 |
| West Virginia | $64.91 | $125.53 |
What the Data Says About Evaluation For Occupational Therapy, Typically 30 Minutes
Across 53 states with reporting providers, CPT code 97165 (Evaluation For Occupational Therapy, Typically 30 Minutes) shows a national average Medicare payment of $76.00 against an average billed charge of $204.28. That gap, a 2.7x markup, or 169% above the Medicare allowed amount, is among the tightest billed-to-paid spreads we track, this code's chargemaster rate tracks unusually close to the Medicare benchmark.
Medicine procedures like this one saw 175.3K services billed to Medicare in 2023 by 10.3K distinct providers, serving 162.2K unique beneficiaries. State-level variation is significant: West Virginia reports the lowest average payment at $64.91, while Alaska reports the highest at $94.62. The 46% spread here is a moderate, fairly ordinary GPCI effect, local cost-of-practice adjustments nudging the allowed amount up or down without reshaping it.
Applying RAND 2024 commercial-to-Medicare ratios specific to the Medicine category (2.15x), the estimated commercial insurance price lands near $216.48, with self-pay cash discounts commonly bringing the figure closer to $131.69. Within Medicine, Evaluation For Occupational Therapy, Typically 30 Minutes ranks #199 of 533 tracked procedures by national average Medicare payment.
What to do with this
If you may have evaluation for occupational therapy, typically 30 minutes done, these steps turn the numbers above into a real-world cost estimate.
- Request a Good Faith Estimate from your provider at least 3 business days before a scheduled procedure, under the No Surprises Act it is an enforceable written price.
- Compare evaluation for occupational therapy, typically 30 minutes costs in your state, Medicare rates vary by locality. Browse states
- Check a hospital’s published cash price, which is often far below the billed charge. Price transparency
- Understand why billed charges run several times the Medicare rate before you negotiate. Read the guide
Figures here are averages and estimates, not a quote. Confirm coverage and out-of-pocket costs with your insurer and provider.
Frequently Asked Questions
How much does Evaluation For Occupational Therapy, Typically 30 Minutes cost?
Medicare's national average payment for Evaluation For Occupational Therapy, Typically 30 Minutes (CPT 97165) is $76.00, with providers billing $204.28 on average; state rates run from $64.91 to $94.62, a meaningful but not extreme spread.
Why do providers charge more than Medicare pays?
Providers set their own chargemaster rates (billed charges), which are typically much higher than what any insurer pays. Medicare pays a fixed rate based on the procedure code and geographic location. The billed charge is relevant mainly for uninsured patients, who may face prices closer to the submitted charge.
How much does Evaluation For Occupational Therapy, Typically 30 Minutes cost with insurance?
With commercial insurance, evaluation for occupational therapy, typically 30 minutes costs an estimated $216.48 on average (range: $151.53-$303.07), a moderate premium over Medicare's $76.00. Without insurance, the estimated cash price is $131.69.
Which state has the lowest cost for Evaluation For Occupational Therapy, Typically 30 Minutes?
West Virginia has the lowest average Medicare payment for Evaluation For Occupational Therapy, Typically 30 Minutes at $64.91, while Alaska has the highest at $94.62 - a meaningful $29.71 spread.
How many providers perform Evaluation For Occupational Therapy, Typically 30 Minutes?
Evaluation For Occupational Therapy, Typically 30 Minutes is a widely-performed procedure: 10.3K providers billed Medicare for it in 2023 across 53 states, together handling 175.3K services for 162.2K beneficiaries.
What is the billed-to-Medicare markup for Evaluation For Occupational Therapy, Typically 30 Minutes?
Providers bill 2.7x what Medicare pays for Evaluation For Occupational Therapy, Typically 30 Minutes - one of the smaller markups in the catalog at 169% above the Medicare rate.
Related Guides
Tips to reduce out-of-pocket costs
Your right to upfront pricing
How Medicare payments work
Decode charges and codes
Why bills exceed actual costs
Geographic pricing factors
Data from CMS Medicare Physician & Other Practitioners (2023).
Read our methodology - how this data is sourced, computed, and verified.
Related
Every figure on PlainProcedure is rendered directly from CMS Medicare Physician & Other Practitioners data, no number is typed in by an editor. This page draws directly on CMS Medicare Physician & Other Practitioners data, no figure is typed in by an editor. See our editorial standards & corrections policy, the methodology behind these numbers, or report a data error.