CMS Price Transparency Data

Occupational therapy (self-care training)

Facility: Valley West Community Hospital

Billing Code: 97535 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 97535
Insurance Median: $169
Cash Discount Price: $188
vs. Medicare Baseline: 5.22x Medicare

The contracted insurance negotiated median rate for a Occupational therapy (self-care training) at Valley West Community Hospital is $169. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $188. Compared to the federal Medicare reimbursement reference rate of $32.4, this hospital’s rate is 5.22x the Medicare baseline. Located in 11 East Pleasant Avenue, Sandwich, IL.

Cash / Self-Pay

$188

Average discount available for prompt cash payment at this facility.

Insurance Median

$169

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: $188 (580%)

Insurance Median: $169 (522%)

Cash: $188 (580% of Medicare)

Ins. Median: $169 (522% 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 522% of the Medicare baseline (a markup of 422%). 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
Blue Cross Blue Shield	$51 - $220	157%
Global Excel [1712]	$51	157%
Humana	$51	157%
Aetna	$68 - $186	210%
Health'S Finest Network [126]	$121 - $229	373%
Cigna	$122 - $130	377%
UnitedHealthcare	$135 - $269	417%
The Alliance [1703]	$146	451%
Choicecare [177]	$181	559%
Healthlink [125]	$202	623%
Multiplan/Phcs [142]	$215 - $269	664%
First Health Plan [6034]	$269	830%

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 $188.
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 Valley West Community Hospital 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.