Occupational therapy (self-care training)
Facility: Ellsworth County Medical Center
Billing Code: 97535 (CPT)
- CPT Billing Code: 97535
- Insurance Median: $54
- Cash Discount Price: $60
- vs. Medicare Baseline: 1.67x 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.
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 |
|---|---|---|
| Triwest -All Plans | $28 | 86% |
| Healthy Blue Mcr Adv | $28 | 86% |
| Humana | $28 - $57 | 86% |
| Va Ccn-All Plans | $28 | 86% |
| Blue Cross Blue Shield | $32 - $34 | 99% |
| UnitedHealthcare | $39 - $60 | 120% |
| First Health - All Plans | $54 | 167% |
| Aetna | $54 | 167% |
| Cigna | $57 | 176% |
| Medicaid / KanCare | $60 | 185% |
| Coventry Mcaid-All Plans | $60 | 185% |
| Healthy Blue Mcaid- All Other Plans | $60 | 185% |
| Providers Care-Wppa-All Plans | $90 | 278% |
Consumer Guidance & Cost Commentary
For CPT code 97535, Occupational therapy (self-care training), the cash price at Ellsworth County Medical Center is $60.00, which matches the facility's negotiated rate and the cash median for this service. While the facility is a Critical Access Hospital in Ellsworth, KS, with a facility rating of 2, patients should note that commercial insurance negotiated rates can sometimes exceed the cash price due to administrative overhead and contract dynamics. For instance, UnitedHealthcare's negotiated range spans $39 to $60, and Humana's range is $28 to $57, meaning some insured patients may pay more than the cash rate. However, for those with high-deductible plans, paying the full $60.00 cash upfront could be more cost-effective than having an insurer pay a negotiated amount that exceeds the cash price, provided the patient's deductible has not yet been met.
To ensure you are not overcharged, it is advisable to request a prompt-pay discount before scheduling your visit, as hospitals often offer significant reductions for upfront payment to bypass costly claims processing. Additionally, if you receive a bill from an out-of-network provider or for services not rendered, you should request a formal itemized billing audit to identify errors such as code unbundling or duplicate charges, which are common in hospital billing. While the Medicare amount for this service is $32.40, serving as a benchmark for fair pricing, the commercial rates listed here reflect the specific contracts between the facility and various payers, including Triwest, Healthy Blue, and Medicaid plans, all of which have negotiated rates ranging from $28 to $90 depending on the specific plan.