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What is a CPT code and why is it important for understanding costs?

A CPT (Current Procedural Terminology) code is a standardized five-digit code used by healthcare professionals to report medical, surgical, and diagnostic services to entities like insurers. It is crucial for understanding costs because it precisely identifies the specific service you received or will receive, allowing you to look up expected charges, compare prices, and understand what your insurance might cover for that particular service.

How do I know what my insurance will cover?

To understand what your insurance will cover, it's best to contact your insurance provider directly. They can provide details specific to your plan, including deductibles, co-pays, co-insurance, and covered services. However, to understand the potential underlying cost of a service before contacting your insurer, you can use Payerprice's fee schedule lookup tool with the relevant CPT code and location, which can then help you have a more informed discussion with your insurance company.

What's the difference between a charge and a negotiated rate?

A 'charge' (or 'list price') is the amount a healthcare provider initially bills for a service, often significantly higher than what is actually paid. A 'negotiated rate' (or 'allowed amount') is the discounted price that a healthcare provider and an insurance company have agreed upon for a specific service. Patients with insurance typically pay based on the negotiated rate, not the initial charge, plus any applicable deductibles, co-pays, or co-insurance.

Where can I find information about fee schedules?

For detailed information on fee schedules, especially those specific to CPT codes and your location, you can use specialized price transparency tools. We recommend Payerprice, which offers a comprehensive fee schedule lookup tool. You can input a CPT code and your specific location to find relevant pricing information.

How can I compare prices for healthcare services in my area?

To compare prices for healthcare services in your area, you can utilize price transparency tools that provide access to fee schedules. Payerprice offers a valuable fee schedule lookup tool where you can search by CPT code and specific location to find and compare the costs of various medical procedures and services, helping you make more informed decisions.

CPT 97164 Fee Schedule

Last Verified: July 2026

Healthcare providers use this code to document and receive reimbursement for visits that address moderate-level medical decision-making, often including multiple diagnoses or prescription management.

Pt Re Eval Est Plan Care, Re Evaluation Of Physical Therapy Established Plan Of Care Requiring These Components An Examination Including A Review Of History And Use Of Standardized Tests And Measures Is Required And Revised Plan Of Care Using A Standardized Patient Assessment Instrument And Or Measurable Assessment Of Functional Outcome Typically 20 Minutes Are Spent Face To Face With The Patient And Or Family

Key Fact	Detail
Service Type	Physical Medicine and Rehabilitation Therapeutic Procedures Physical Medicine and Rehabilitation Evaluations
Common Place of Service	11 - Office None
Common Modifiers	GP - Services delivered under an outpatient physical therapy plan of care None 59 - Distinct Procedural Service
Complexity Level	Low
Medicare Fee Schedule	View Medicare rates for 97164

National average reimbursement for CPT 97164 by major payers:

$71.84

$61.44

$62.68

$77.64

Preview provider-level rates for...

For billing codeCPT 97164

Payer	Code	Rate	NPI	Tax ID	State	Specialty
United	97164	$52.00	1821869348 - HELENA SPOONER	871486879	NY	Family Medicine Physician (207Q00000X)
United	97164	$83.23	1154369288 - MARK VERY	134000192 - ENT AND ALLERGY ASSOCIATES, LLP	NY	Otolaryngology Physician (207Y00000X)
United	97164	$62.88	1689640245 - DIMITRIA PAPADOPOULOS	680596852 - (NY) BELLMORE DERMATOLOGY PLLC	NY	Dermatology Physician (207N00000X)
United	97164	$238.49	1306003793 - JAMES HARDING	133278548 - (NY) MEMORIAL DEVELOPMENTAL CHEMO GROUP	NY	Hematology & Oncology Physician (207RH0003X)
United	97164	$47.31	1639288640 - HENRY ROMAN	582501863 - ESSEN MEDICAL ASSOCIATES, P.C.	NY	Internal Medicine Physician (207R00000X)
United	97164	$62.88	1245792043 - LARRY MALKIN	113361987 - (NY) MAIMONIDES MEDICAL CENTER MAIMONIDES PRIMARY CARE FPP	NY	Internal Medicine Physician (207R00000X)
United	97164	$116.19	1790762730 - MEGAN COLLINS	135562308 - NEW YORK UNIVERSITY	NY	Internal Medicine Physician (207R00000X)
United	97164	$52.00	1417933144 - GENE COPPA	112965586 - (NY) NORTHWELL HEALTHCARE INC	NY	Surgery Physician (208600000X)
United	97164	$67.12	1942299292 - OLEG DULKIN	161576637 - FAXTON-ST LUKES HEALTHCARE	NY	Family Medicine Physician (207Q00000X)
United	97164	$42.00	1932553252 - CHERYL ROZARIO	161029490 - (NY) ALLERGY	NY	Internal Medicine Physician (207R00000X)
United	97164	$42.00	1457394413 - ALBERT DEVLIN	160743966 - (NY) CLIFTON SPRINGS SANITARIUM CO	NY	Internal Medicine Physician (207R00000X)
United	97164	$145.47	1316332745 - UGOCHI NWOSU	131623978	NY	Internal Medicine Physician (207R00000X)
United	97164	$47.31	1528003019 - GALINA KLETSMAN	202469126	NY	Family Medicine Physician (207Q00000X)
United	97164	$52.00	1265433098 - STUART KANTERMAN	453023019 - (NY) NORTH SHORE-LIJ MEDICAL PC	NY	Internal Medicine Physician (207R00000X)
United	97164	$42.00	1437151354 - AMY HARRINGTON	223385574 - (NY) STRONG OBSTETRICSGYNECOLOGY GROUP	NY	Obstetrics & Gynecology Physician (207V00000X)
United	99202	$100.00	1234567890	1234567890	CA	Cardiologist
United	99202	$100.00	1234567890	1234567890	CA	Cardiologist
United	99202	$100.00	1234567890	1234567890	CA	Cardiologist
United	99202	$100.00	1234567890	1234567890	CA	Cardiologist
United	99202	$100.00	1234567890	1234567890	CA	Cardiologist
United	99202	$100.00	1234567890	1234567890	CA	Cardiologist
United	99202	$100.00	1234567890	1234567890	CA	Cardiologist
United	99202	$100.00	1234567890	1234567890	CA	Cardiologist
United	99202	$100.00	1234567890	1234567890	CA	Cardiologist
United	99202	$100.00	1234567890	1234567890	CA	Cardiologist

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CPT 97164 vs. Other Physical Medicine and Rehabilitation Evaluations Codes

The CPT 97164 code is part of the Physical Medicine and Rehabilitation Therapeutic Procedures services used for Physical Medicine and Rehabilitation Evaluations. It represents a moderate-complexity encounter and is one of several codes that vary based on time spent, level of medical decision-making, and documentation requirements.

The CPT 97164 code involves more provider time and moderate medical decision-making, unlike lower-level codes that require less time and simpler assessments. It typically includes multiple diagnoses, medication management, or test interpretation, leading to higher reimbursement and more detailed documentation requirements.

Code	Complexity	Description
97163-CPT	Low	Pt Eval High Complex 45 Min, Physical Therapy Evaluation High Complexity Requiring These Components A History Of Present Problem With 3 Or More Personal Factors And Or Comorbidities That Impact The Plan Of Care An Examination Of Body Systems Using Standardized Tests And Measures Addressing A Total Of 4 Or More Elements From Any Of The Following Body Structures And Functions Activity Limitations And Or Participation Restrictions A Clinical Presentation With Unstable And Unpredictable Characteristics And Clinical Decision Making Of High Complexity Using Standardized Patient Assessment Instrument And Or Measurable Assessment Of Functional Outcome Typically 45 Minutes Are Spent Face To Face With The Patient And Or Family
97164-CPT	Low	Pt Re Eval Est Plan Care, Re Evaluation Of Physical Therapy Established Plan Of Care Requiring These Components An Examination Including A Review Of History And Use Of Standardized Tests And Measures Is Required And Revised Plan Of Care Using A Standardized Patient Assessment Instrument And Or Measurable Assessment Of Functional Outcome Typically 20 Minutes Are Spent Face To Face With The Patient And Or Family
97165-CPT	Low	Ot Eval Low Complex 30 Min, Occupational Therapy Evaluation Low Complexity Requiring These Components An Occupational Profile And Medical And Therapy History Which Includes A Brief History Including Review Of Medical And Or Therapy Records Relating To The Presenting Problem An Assessment S That Identifies 1 3 Performance Deficits Ie Relating To Physical Cognitive Or Psychosocial Skills That Result In Activity Limitations And Or Participation Restrictions And Clinical Decision Making Of Low Complexity Which Includes An Analysis Of The Occupational Profile Analysis Of Data From Problem Focused Assessment S And Consideration Of A Limited Number Of Treatment Options Patient Presents With No Comorbidities That Affect Occupational Performance Modification Of Tasks Or Assistance Eg Physical Or Verbal With Assessment S Is Not Necessary To Enable Completion Of Evaluation Component Typically 30 Minutes Are Spent Face To Face With The Patient And Or Family

What is a fee schedule?

A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 97164. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.

Understanding the 97164 fee schedule helps patients estimate costs and providers optimize billing for accurate reimbursements.

Factors that affect fee schedules

Medicare & Medicaid Rates

Government-set reimbursement amounts

Private Insurance Rates

Negotiated rates between providers and insurance companies

Geographic Location

Costs may be higher in urban areas.

Provider Type

Hospital providers may have different rates than private practice.

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