Occupational therapy (self-care training)
Facility: Lane County Hospital
Billing Code: 97535 (CPT)
- CPT Billing Code: 97535
- Insurance Median: $90
- Cash Discount Price: $90
- vs. Medicare Baseline: 2.78x Medicare
Average discount available for prompt cash payment at this facility.
Median negotiated contract rate across all mapped commercial carriers.
Standard federal government reimbursement rate for this code.
Visual Cost Comparison vs. 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 278% of the Medicare baseline (a markup of 178%). Patients with high-deductible plans or out-of-network benefits may face excessive out-of-pocket costs.
Out-of-Pocket Cost Estimator
Estimate whether it is more economical to use your insurance or pay the upfront self-pay cash rate.
Commercial Insurance Negotiated Rates
Negotiated contract ranges established by major commercial carriers at this facility.
| Carrier / Plan Group | Contract Rate Range | vs. Medicare Reference |
|---|---|---|
| UnitedHealthcare | $81 - $90 | 250% |
| Aetna | $81 - $86 | 250% |
| Medicaid / KanCare | $90 - $99 | 278% |
| Healthy Blue Mcr Adv - All Other Plans | $90 | 278% |
| Healthy Blue Mcaid | $90 | 278% |
| Wppa Providers-All Plans | $135 | 417% |
Consumer Guidance & Cost Commentary
For the CPT code 97535, representing occupational therapy self-care training, the cash and negotiated rates at Lane County Hospital in Dighton are both $90.00. This price is identical to the state average for this service, indicating that the facility's pricing aligns with regional standards for this specific procedure. While commercial payers like UnitedHealthcare and Aetna have negotiated rates ranging from $81 to $90, the cash price remains the same as the Medicare benchmark of $32.40 plus a standard markup. Because the cash price matches the negotiated amount, patients with high-deductible plans may find paying out-of-pocket directly to the hospital offers no financial advantage over using insurance, as the insurer would likely cover the same $90.00 rate.
Patients should verify their specific plan details before scheduling, as some commercial contracts may have different allowed amounts than the published median. It is important to note that while the facility is a Critical Access Hospital owned by a Government Hospital District, the pricing structure here does not show a significant deviation from the typical 200% to 300% markup often seen in commercial billing relative to Medicare. If you are considering paying cash, you should explicitly ask the billing department about any "self-pay" or "prompt-pay" discounts that might apply, as these can sometimes reduce the final cost even when the listed cash rate is equal to the negotiated rate. Always request an itemized bill before payment to ensure no unbundled codes or services not rendered are included in the final charge.