Occupational therapy (self-care training)
Facility: Hiawatha Community Hospital
Billing Code: 97535 (CPT)
- CPT Billing Code: 97535
- Insurance Median: $152
- Cash Discount Price: $186
- vs. Medicare Baseline: 4.69x 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 469% of the Medicare baseline (a markup of 369%). 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 |
|---|---|---|
| Blue Cross Blue Shield | $32 - $34 | 99% |
| UnitedHealthcare | $61 - $177 | 188% |
| Aetna | $61 - $166 | 188% |
| Humana | $62 - $77 | 191% |
| Ambetter / Centene | $73 - $91 | 225% |
| Centrus Health Direct - All Plans | $124 - $154 | 383% |
| Oscar - All Plans | $124 - $154 | 383% |
| Preferred Hlth - All Plans | $148 - $185 | 457% |
| Wppa Providrs Care - All Plans | $157 - $196 | 485% |
| Cigna | $157 - $196 | 485% |
| Multiplan - All Plans | $160 - $200 | 494% |
| Midlands Choice - All Plans | $160 - $200 | 494% |
| Healthy Blue Mcaid - All Plans | $165 - $206 | 509% |
Consumer Guidance & Cost Commentary
For the Occupational therapy (self-care training) service at Hiawatha Community Hospital, the cash price is $186.00, which matches the facility's median negotiated rate of $155.00 and the state average of $152.00. While this service is covered by 13 different payers with negotiated rates ranging from $32 to $206, patients with high-deductible plans may find paying the cash price of $186.00 more cost-effective than relying on insurance, as some commercial negotiated rates exceed the cash amount. It is important to note that while the facility is a Critical Access Hospital in Kansas, the cash rate represents the baseline for self-pay patients, and hospitals often offer additional "self-pay" or "prompt-pay" discounts that should be requested directly before scheduling care to potentially lower the final bill.
The Medicare benchmark for this procedure is $32.40, which serves as the objective baseline for evaluating pricing markups; commercial rates are significantly higher due to administrative costs and contract structures. Although the facility's cash price is higher than the Medicare amount, this reflects the true cost of delivery adjusted for local wage indexes rather than arbitrary list pricing. Patients should be aware that balance billing is generally prohibited for emergency care and non-emergency services from out-of-network providers at in-network facilities under the No Surprises Act, but they should still request an itemized billing audit if they receive unexpected charges. To avoid surprise costs, consumers should verify their deductible status and explicitly ask for a prompt-pay discount or self-pay classification at registration to ensure they are not inadvertently triggering higher insurance processing fees.