CMS Price Transparency Data

Occupational therapy (self-care training)

Facility: St Josephs Community Hospital West Bend

Billing Code: 97535 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 97535
Insurance Median: $116
Cash Discount Price: $79
vs. Medicare Baseline: 3.58x Medicare

The contracted insurance negotiated median rate for a Occupational therapy (self-care training) at St Josephs Community Hospital West Bend is $116. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $79. Compared to the federal Medicare reimbursement reference rate of $32.4, this hospital’s rate is 3.58x the Medicare baseline. Located in 3200 Pleasant Valley Road, West Bend, WI.

Cash / Self-Pay

$79

Average discount available for prompt cash payment at this facility.

Insurance Median

$116

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: $79 (244%)

Insurance Median: $116 (358%)

Cash: $79 (244% of Medicare)

Ins. Median: $116 (358% 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 358% of the Medicare baseline (a markup of 258%). 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
Allwell	$31	96%
Blue Cross Blue Shield	$31 - $327	96%
Community Care	$31	96%
Health Partners	$31 - $93	96%
Humana	$31	96%
Icare	$31	96%
Molina	$31	96%
Network Health Plan	$31 - $263	96%
Security Health Plan Secure Savers	$31	96%
UnitedHealthcare	$31 - $370	96%
Aetna	$32 - $100	99%
Care Wisconsin	$32	99%
Centivo	$43 - $47	133%
Froedtert South	$60	185%
Chorus Community Health Plan	$61	188%
Common Ground	$86	265%
Health Payment Systems	$90 - $116	278%
Wisconsin Physician Services	$114	352%
Trilogy	$117	361%
Americas Choice	$124	383%
Healtheos	$124	383%
Multiplan/Private Healthcare Systems	$124	383%
First Health Network	$126	389%
Hfn	$129	398%
Ibsi Passport	$129	398%
Cigna	$136	420%
Healthsmart	$136	420%
Sheboygan Employers Health Network	$397	1225%

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 $79.
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 St Josephs Community Hospital West Bend 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.