Occupational therapy (therapeutic activities)
Facility: Rooks County Health Center
Billing Code: 97530 (CPT)
- CPT Billing Code: 97530
- Insurance Median: $93
- Cash Discount Price: $78
- vs. Medicare Baseline: 2.65x 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 $35.07 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 265% of the Medicare baseline (a markup of 165%). 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 |
|---|---|---|
| Celtic Mcr Adv | $49 | 140% |
| Veterans Admin - All Plans | $49 | 140% |
| Tricare | $49 | 140% |
| Celtic Comm - All Other Plans | $54 | 154% |
| Blue Cross Blue Shield | $57 | 163% |
| Aetna | $93 | 265% |
| UnitedHealthcare | $93 | 265% |
| Preferred Benefits Admin | $93 | 265% |
| Health Partners - All Plans | $98 | 279% |
| Preferred Hlthcare - All Other Plans | $98 | 279% |
| Healthy Blue Mcaid - All Plans | $104 | 297% |
Consumer Guidance & Cost Commentary
For CPT code 97530, representing occupational therapy therapeutic activities, the facility's cash median rate of $78.00 is notably lower than the negotiated rates paid by most major insurers, which range from $49 to $104. While the cash price is the lowest amount a patient could theoretically pay, it is important to note that for patients with high-deductible plans, the insurance negotiated rate may still be more cost-effective if their out-of-pocket costs exceed the cash price. The facility, Rooks County Health Center, is a Critical Access Hospital in Plainville, KS, and offers a prompt-pay discount for self-pay patients who settle their bill upfront, which can further reduce the final amount owed.
When evaluating the value of this service, it is essential to compare rates against federal benchmarks rather than the hospital's full list price. The Medicare amount for this procedure is $35.07, which serves as the objective baseline for fair pricing; commercial negotiated rates often average between 200% and 300% of this figure, though fair pricing is typically defined as 120% to 150%. Patients should be aware that balance billing is generally prohibited for out-of-network services at in-network facilities under the No Surprises Act, and they should always request an itemized bill to ensure no unbundled charges or services not rendered are included in the final invoice.