CMS Price Transparency Data

Occupational therapy (self-care training)

Facility: Gundersen St Josephs Hospital and Clinics

Billing Code: 97535 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 97535
Insurance Median: $137
Cash Discount Price: $143
vs. Medicare Baseline: 4.23x Medicare

The contracted insurance negotiated median rate for a Occupational therapy (self-care training) at Gundersen St Josephs Hospital and Clinics is $137. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $143. Compared to the federal Medicare reimbursement reference rate of $32.4, this hospital’s rate is 4.23x the Medicare baseline. Located in 400 Water Ave, Hillsboro, WI.

Cash / Self-Pay

$143

Average discount available for prompt cash payment at this facility.

Insurance Median

$137

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: $143 (441%)

Insurance Median: $137 (423%)

Cash: $143 (441% of Medicare)

Ins. Median: $137 (423% 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 423% of the Medicare baseline (a markup of 323%). 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
Amerigroup	$12	37%
Security Health Plan	$48	148%
Blue Cross Blue Shield	$74 - $170	228%
Iowa Total Care	$74	228%
Managed Health Service	$74	228%
Ucare	$128 - $197	395%
Alliance	$130 - $209	401%
UnitedHealthcare	$130 - $172	401%
Quartz	$134	414%
Cigna	$202	623%
Aspirus Arise Health	$204	630%
Humana	$209	645%
Multiplan/Healtheos	$214 - $234	660%
Coventry Health Care	$234	722%

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 $143.
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 Gundersen St Josephs Hospital and Clinics 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.