CMS Price Transparency Data

Occupational therapy (self-care training)

Facility: Stoughton Hospital

Billing Code: 97535 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 97535
Insurance Median: $107
Cash Discount Price: $101
vs. Medicare Baseline: 3.30x Medicare

The contracted insurance negotiated median rate for a Occupational therapy (self-care training) at Stoughton Hospital is $107. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $101. Compared to the federal Medicare reimbursement reference rate of $32.4, this hospital’s rate is 3.30x the Medicare baseline. Located in 900 Ridge St, Stoughton, WI.

Cash / Self-Pay

$101

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: $101 (312%)

Insurance Median: $107 (330%)

Cash: $101 (312% 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
Medicaid / KanCare	$36	111%
Tricare	$44	136%
Healthnet Mcr Adv - All Plans	$49	151%
Dean Health Insurance Med Adv	$52	160%
Humana	$52 - $166	160%
Quartz Mcr Adv	$52	160%
Security Health/First Health - All Plans	$52	160%
Aetna	$55 - $156	170%
UnitedHealthcare	$81 - $147	250%
Quartz Health Solutions - All Other Lans	$98	302%
Alliance - All Plans	$107	330%
Dean Health Insurance Epo	$114	352%
Dean Health Insurance Comm - All Other Plans	$138	426%
Geha - All Plans	$138	426%
Cigna	$147	454%
Wisconsin Ppo Ppa Direct - All Plans	$147	454%
Blue Cross Blue Shield	$160	494%
Wps - All Plans	$166	512%

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 $101.
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 Stoughton 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.