CMS Price Transparency Data

Occupational therapy (self-care training)

Facility: Sanford Hillsboro

Billing Code: 97535 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 97535
Insurance Median: $123
Cash Discount Price: $119
vs. Medicare Baseline: 3.80x Medicare

The contracted insurance negotiated median rate for a Occupational therapy (self-care training) at Sanford Hillsboro is $123. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $119. Compared to the federal Medicare reimbursement reference rate of $32.4, this hospital’s rate is 3.80x the Medicare baseline. Located in 12 Third Street Se, Hillsboro, ND.

Cash / Self-Pay

$119

Average discount available for prompt cash payment at this facility.

Insurance Median

$123

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: $119 (367%)

Insurance Median: $123 (380%)

Cash: $119 (367% of Medicare)

Ins. Median: $123 (380% 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 380% of the Medicare baseline (a markup of 280%). 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	$36 - $138	111%
Sanford Health Plan Align	$68	210%
Ucare	$73 - $131	225%
Aetna	$74 - $129	228%
Health Partners	$74 - $116	228%
Medicare (plans)	$74	228%
UnitedHealthcare	$74 - $124	228%
Primewest	$75	231%
Security Health Plan	$82	253%
Sanford Health Plan	$118 - $138	364%
Medica	$123 - $131	380%
First Choice Health Network	$134	414%
Healthez	$134	414%
Multiplan	$134	414%

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 $119.
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 Sanford Hillsboro 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.