CMS Price Transparency Data

Occupational therapy (self-care training)

Facility: Wellspan Ephrata Community Hospital

Billing Code: 97535 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 97535
Insurance Median: $107
Cash Discount Price: $137
vs. Medicare Baseline: 3.30x Medicare

The contracted insurance negotiated median rate for a Occupational therapy (self-care training) at Wellspan Ephrata Community Hospital is $107. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $137. Compared to the federal Medicare reimbursement reference rate of $32.4, this hospital’s rate is 3.30x the Medicare baseline. Located in 169 Martin Avenue, Ephrata, PA.

Cash / Self-Pay

$137

Average discount available for prompt cash payment at this facility.

Insurance Median

$107

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: $137 (423%)

Insurance Median: $107 (330%)

Cash: $137 (423% of Medicare)

Ins. Median: $107 (330% 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 330% of the Medicare baseline (a markup of 230%). 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
Medicare (plans)	$27 - $33	83%
Aetna	$31 - $144	96%
Medicaid / KanCare	$47 - $57	145%
Highmark	$48 - $141	148%
Blue_Cross	$70 - $120	216%
Cigna	$95 - $119	293%
Wellspan_Capital_Blue_Cross	$100 - $119	309%
Geisinger	$101 - $121	312%
Independence_Blue_Cross	$101 - $121	312%
Tower Health	$101 - $127	312%
Upmc	$101 - $149	312%
Phc	$109 - $132	336%
First_Health_Network	$133	410%
United_Healthcare	$147 - $175	454%

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 $137.
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 Wellspan Ephrata Community Hospital 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.