CMS Price Transparency Data

Occupational therapy (therapeutic activities)

Facility: Stoughton Hospital

Billing Code: 97530 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 97530
Insurance Median: $117
Cash Discount Price: $111
vs. Medicare Baseline: 3.34x Medicare

The contracted insurance negotiated median rate for a Occupational therapy (therapeutic activities) at Stoughton Hospital is $117. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $111. Compared to the federal Medicare reimbursement reference rate of $35.07, this hospital’s rate is 3.34x the Medicare baseline. Located in 900 Ridge St, Stoughton, WI.

Cash / Self-Pay

$111

Average discount available for prompt cash payment at this facility.

Insurance Median

$117

Median negotiated contract rate across all mapped commercial carriers.

Medicare Reference Rate

$35.07

Standard federal government reimbursement rate for this code.

Visual Cost Comparison vs. Medicare

Medicare Reference Baseline: $35.07 (100%)

Cash / Self-Pay: $111 (317%)

Insurance Median: $117 (334%)

Cash: $111 (317% of Medicare)

Ins. Median: $117 (334% of Medicare)

Understanding this gauge: We use the federal Medicare rate of $35.07 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 334% of the Medicare baseline (a markup of 234%). 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	$42	120%
Tricare	$48	137%
Healthnet Mcr Adv - All Plans	$53	151%
Dean Health Insurance Med Adv	$56	160%
Humana	$56 - $181	160%
Quartz Mcr Adv	$56	160%
Security Health/First Health - All Plans	$56	160%
Aetna	$60 - $171	171%
UnitedHealthcare	$88 - $161	251%
Quartz Health Solutions - All Other Lans	$109	311%
Alliance - All Plans	$117	334%
Dean Health Insurance Epo	$124	354%
Dean Health Insurance Comm - All Other Plans	$151	431%
Geha - All Plans	$151	431%
Cigna	$161	459%
Wisconsin Ppo Ppa Direct - All Plans	$161	459%
Blue Cross Blue Shield	$175	499%
Wps - All Plans	$181	516%

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 $111.
Request and sign a "Waiver of Insurance Submission" to prevent automatic billing.
Verify CPT Code matches exactly: 97530.

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 97530.
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.