OT EVAL HIGH COMPLEX at Samaritan Medical Center

Watertown, NY

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Pricing by billing methodology

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Payers reporting CPT 97167-GO at Samaritan Medical Center

Negotiated rates from the hospital’s own file: 4 payers, 7 plan rates. A facility fee, a professional fee, a per diem and a case rate are different bills, so each is listed on its own. Open a payer to see it across hospitals.

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1	Excellus medicare advantage facility · case rate · outpatient	$98	$98	—	—	—	$98 – $98
2	WellCare medicare advantage facility · case rate · outpatient	$98	$98	—	—	—	$98 – $98
3	Aetna medicare advantage facility · case rate · outpatient	$100	$100	—	—	—	$100 – $100
4	UnitedHealthcare medicare advantage facility · case rate · outpatient	$101	$101	—	—	—	$101 – $101
5	Aetna commercial facility · percent of total billed charges · outpatientfrom % of charges	$190	$190	—	—	—	$190 – $190
6	UnitedHealthcare commercial facility · case rate · outpatient	$275	$275	—	—	—	$275 – $275
7	Excellus commercial facility · case rate · outpatient	$450	$450	—	—	—	$450 – $450

Last updated: Feb 2, 2026

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