CMS Price Transparency Data

Occupational therapy (self-care training)

Facility: Adventist Health St Helena

Billing Code: 97535 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 97535
Insurance Median: $188
Cash Discount Price: $44
vs. Medicare Baseline: 5.80x Medicare

The contracted insurance negotiated median rate for a Occupational therapy (self-care training) at Adventist Health St Helena is $188. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $44. Compared to the federal Medicare reimbursement reference rate of $32.4, this hospital’s rate is 5.80x the Medicare baseline. Located in 10 Woodland Road, Saint Helena, CA.

Cash / Self-Pay

$44

Average discount available for prompt cash payment at this facility.

Insurance Median

$188

Median negotiated contract rate across all mapped commercial carriers.

Medicare Reference Rate

$32.4

Standard federal government reimbursement rate for this code.

Visual Cost Comparison vs. Medicare

Medicare Reference Baseline: $32.4 (100%)

Cash / Self-Pay: $44 (136%)

Insurance Median: $188 (580%)

Cash: $44 (136% of Medicare)

Ins. Median: $188 (580% of Medicare)

Understanding this gauge: We use the federal Medicare rate of $32.4 as the cost baseline. Rates below the baseline represent excellent value. In-network commercial rates commonly hover around 150% - 250% of Medicare, while rates exceeding 300% are elevated. Hover over the green and blue markers to view detailed calculations.

Elevated Commercial Rate Alert (Value-Gap)

The negotiated rate at this facility is 580% of the Medicare baseline (a markup of 480%). Patients with high-deductible plans or out-of-network benefits may face excessive out-of-pocket costs.

Consult Patient Advocate

Out-of-Pocket Cost Estimator

Estimate whether it is more economical to use your insurance or pay the upfront self-pay cash rate.

Billing Status

Remaining Deductible ($)

Your Coinsurance Rate (%)

Input your details and click calculate to compare out-of-pocket costs.

Commercial Insurance Negotiated Rates

Negotiated contract ranges established by major commercial carriers at this facility.

Carrier / Plan Group	Contract Rate Range	vs. Medicare Reference
Va Medi-Cal	$8	25%
Blue Shield Bh Mcr Adv	$39	120%
Blue Shield Mcr Adv	$39	120%
Kaiser Mcr Adv	$39	120%
Tricare	$39	120%
UnitedHealthcare	$39 - $189	120%
Va Mcr - All Other Plans	$39	120%
Ah Employee Health Plan - All Plans	$69	213%
Aetna	$128	395%
Blue Shield Behav Hlth	$133	410%
Phcs-All Plans	$163	503%
Healthnet-All Plans	$181	559%
Interplan-All Plans	$192	593%
Choicecare-All Plans	$207	639%
Beech Street-All Plans	$222	685%
Cigna	$237	731%
Kaiser-All Other Plans	$243	750%
Health Management Network-All Plans	$252	778%
Galaxy Network-All Plans	$266	821%
Three Rivers-All Plans	$266	821%
Blue Shield Epn-All Other Plans	$286	883%
Blue Shield Non-Epn	$294	907%
Western Growers-All Plans	$297	917%
Blue Cross Blue Shield	$332 - $447	1025%

Self-Pay Upfront Cash Action Plan

Request a "Self-Pay classification" with the billing desk before receiving care.
Ask for a written "Prompt-Pay Discount" agreement quoting the price of $44.
Request and sign a "Waiver of Insurance Submission" to prevent automatic billing.
Verify CPT Code matches exactly: 97535.

Insurance In-Network Protection Plan

Contact your insurance company to confirm Adventist Health St Helena is fully in-network.
Ask your insurer if "Prior Authorization" is required for CPT code 97535.
Confirm the specific physician or imaging center is also in-network (not just the hospital building).
Audit your Explanation of Benefits (EOB) against the final itemized hospital invoice.