Physical therapy (gait training)
Facility: Lane County Hospital
Billing Code: 97116 (CPT)
- CPT Billing Code: 97116
- Insurance Median: $90
- Cash Discount Price: $90
- vs. Medicare Baseline: 3.10x Medicare
Average discount available for prompt cash payment at this facility.
Median negotiated contract rate across all mapped commercial carriers.
Standard federal government reimbursement rate for this code.
Visual Cost Comparison vs. Medicare
Understanding this gauge: We use the federal Medicare rate of $29.06 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 310% of the Medicare baseline (a markup of 210%). Patients with high-deductible plans or out-of-network benefits may face excessive out-of-pocket costs.
Out-of-Pocket Cost Estimator
Estimate whether it is more economical to use your insurance or pay the upfront self-pay cash rate.
Commercial Insurance Negotiated Rates
Negotiated contract ranges established by major commercial carriers at this facility.
| Carrier / Plan Group | Contract Rate Range | vs. Medicare Reference |
|---|---|---|
| Aetna | $81 - $86 | 279% |
| UnitedHealthcare | $81 - $90 | 279% |
| Healthy Blue Mcr Adv - All Other Plans | $90 | 310% |
| Healthy Blue Mcaid | $90 | 310% |
| Medicaid / KanCare | $90 - $99 | 310% |
| Wppa Providers-All Plans | $135 | 465% |
Consumer Guidance & Cost Commentary
For the CPT code 97116, representing physical therapy gait training at Lane County Hospital in Dighton, Kansas, the cash price is $90.00, which matches the facility's median negotiated rate and the median amount paid by insurers. This rate is significantly higher than the Medicare benchmark of $29.06, indicating a markup of 3.1 times the federal baseline. While commercial payers like Aetna and UnitedHealthcare negotiate rates ranging from $81 to $90, these amounts remain well above the Medicare cost basis. Because commercial negotiated rates often include administrative overhead and do not reflect the true cost of care, patients with high-deductible plans may find paying the cash price of $90.00 directly more cost-effective than relying on insurance, which could result in higher out-of-pocket expenses if the deductible is not yet met.
Patients should be aware that while the No Surprises Act protects against balance billing for out-of-network providers at in-network facilities, it does not eliminate the potential for unexpected charges if ancillary services are billed separately. To ensure transparency, consumers should request a full itemized bill before paying, as summary invoices can obscure unbundled codes or services not rendered. Additionally, since hospitals often offer prompt-pay discounts for upfront cash payments, it is advisable to contact the billing department prior to scheduling to confirm self-pay rates and ask about any available discounts. Given that the facility is a Critical Access Hospital owned by the Government Hospital District, verifying the specific payment classification at check-in is crucial to avoiding automatic claims submission that might void potential cash savings.