CMS Price Transparency Data

Occupational therapy (self-care training)

Facility: Hospital for Special Surgery

Billing Code: 97535 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 97535
Insurance Median: $184
Cash Discount Price: $221
vs. Medicare Baseline: 5.68x Medicare

The contracted insurance negotiated median rate for a Occupational therapy (self-care training) at Hospital for Special Surgery is $184. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $221. Compared to the federal Medicare reimbursement reference rate of $32.4, this hospital’s rate is 5.68x the Medicare baseline. Located in 535 East 70Th Street, New York, NY.

Cash / Self-Pay

$221

Average discount available for prompt cash payment at this facility.

Insurance Median

$184

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: $221 (682%)

Insurance Median: $184 (568%)

Cash: $221 (682% of Medicare)

Ins. Median: $184 (568% 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 568% of the Medicare baseline (a markup of 468%). 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	$10 - $203	31%
Affinity By Molina Health Plan [1005]	$77 - $169	238%
Connecticare [1039]	$77	238%
Emblem Health [1043]	$77 - $187	238%
Medicare (plans)	$77	238%
UnitedHealthcare	$77 - $275	238%
Oxford [1096]	$169 - $218	522%
Aetna	$184 - $204	568%
Christian Brothers [1034]	$184 - $204	568%
Meritain Health [1085]	$184 - $204	568%
Nippon Life [1092]	$184 - $204	568%
Webtpa [1356]	$184 - $204	568%
Apwu [1016]	$185	571%
Cigna	$185	571%
Nalc [1090]	$185	571%
Qualcare [1101]	$185	571%
Wellfleet [1361]	$185	571%
Student Resources [1103]	$187 - $241	577%
Harvard Pilgrim [1057]	$213 - $275	657%
Fidelis Essential [1323]	$221	682%
Geha [1053]	$241	744%

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 $221.
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 Hospital for Special Surgery 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.