Physical therapy (gait training)
Facility: Rawlins County Health Center
Billing Code: 97116 (CPT)
- CPT Billing Code: 97116
- Insurance Median: $60
- Cash Discount Price: $72
- vs. Medicare Baseline: 2.06x 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 206% of the Medicare baseline (a markup of 106%). 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 |
|---|---|---|
| Blue Cross Blue Shield | $46 | 158% |
| UnitedHealthcare | $60 - $87 | 206% |
Consumer Guidance & Cost Commentary
For the CPT code 97116, representing physical therapy gait training, Rawlins County Health Center lists a gross charge of $85.00. While the facility's cash median price is $72.00, which is lower than the gross charge, it is important to note that commercial insurance rates often exceed cash prices due to administrative overhead and contract structures. In this case, the negotiated rates for UnitedHealthcare range from $60.00 to $87.00 across four plans, and Blue Cross Blue Shield has a single plan at $46.00. Patients should be aware that paying cash upfront can sometimes be more cost-effective than using insurance if their plan's negotiated rate is higher than the cash price, though this depends on individual deductible status and plan specifics.
When evaluating the cost relative to government benchmarks, the facility's cash rate of $72.00 is approximately 2.1 times the Medicare amount of $29.06 for this service. Under Medicare benchmarking principles, fair pricing is typically defined as 120% to 150% of the Medicare rate, whereas commercial negotiated rates often average between 200% and 300% of Medicare. To maximize savings, patients should verify if the hospital offers "self-pay" or "prompt-pay" discounts, which can reduce the final bill by 20% to 50% for upfront payment. Additionally, since the No Surprises Act prohibits balance billing for out-of-network providers at in-network facilities, patients should ensure they understand their coverage before scheduling to avoid unexpected costs.