CMS Price Transparency Data

Occupational therapy (self-care training)

Facility: Saint Michael's Medical Center

Billing Code: 97535 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 97535
Insurance Median: $49
Cash Discount Price: $36
vs. Medicare Baseline: 1.51x Medicare

The contracted insurance negotiated median rate for a Occupational therapy (self-care training) at Saint Michael's Medical Center is $49. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $36. Compared to the federal Medicare reimbursement reference rate of $32.4, this hospital’s rate is 1.51x the Medicare baseline. Located in 111 Central Avenue, Newark, NJ.

Cash / Self-Pay

$36

Average discount available for prompt cash payment at this facility.

Insurance Median

$49

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: $36 (111%)

Insurance Median: $49 (151%)

Cash: $36 (111% of Medicare)

Ins. Median: $49 (151% 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.

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
Tricare	$29	90%
Aetna	$36 - $77	111%
Amerihealth	$36	111%
Horizon	$36 - $153	111%
Humana	$36	111%
Medicare (plans)	$36	111%
New Jersey Out of State	$36	111%
UnitedHealthcare	$36 - $499	111%
Wellpoint Amerigroup	$36	111%
Wellcare	$37 - $49	114%
Clover Health	$38	117%
Curana	$38	117%
Fairprice Healthcare Holdings - Fphh	$43	133%
Employer Direct Healthcare	$51	157%
Naphcare	$56	173%
Coventry	$72	222%
Cigna	$158	488%

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 $36.
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 Saint Michael's Medical Center 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.