Physical therapy (gait training)
Facility: Holton Community Hospital
Billing Code: 97116 (CPT)
- CPT Billing Code: 97116
- Insurance Median: $60
- Cash Discount Price: $55
- 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 |
|---|---|---|
| UnitedHealthcare | $39 - $100 | 134% |
| Aetna | $39 - $73 | 134% |
| Kansas Superior Select - All Plans | $39 | 134% |
| Humana | $39 | 134% |
| Blue Cross Blue Shield | $46 | 158% |
| Preferred Health Professionals | $60 | 206% |
| Preferred Health Freedom | $60 | 206% |
| Preferred Health Fn Select - All Other Plans | $60 | 206% |
| Wppa Providers - All Plans | $69 | 237% |
| Medicaid / KanCare | $73 | 251% |
Consumer Guidance & Cost Commentary
For the CPT code 97116, representing physical therapy gait training, Holton Community Hospital lists a cash median price of $55.00, which is lower than the facility's negotiated rates of $60.00 and the gross charge of $73.00. While the Medicare benchmark for this service is $29.06, the facility's cash rate exceeds the Medicare amount by approximately 88%, reflecting a markup common in the healthcare industry. Patients with high-deductible plans may find paying the cash price of $55.00 more cost-effective than using insurance, as commercial payers like UnitedHealthcare and Aetna negotiate rates starting at $39.00 and reaching up to $100.00, which could result in higher out-of-pocket costs if the patient's deductible has not been met.
To minimize potential surprise costs, consumers should verify their specific plan's allowed amount and ask the hospital directly about "self-pay" or "prompt-pay" discounts, which can reduce the final bill by 20% to 50% if paid upfront. It is also important to request a detailed, itemized bill rather than accepting a summary invoice, as over 80% of hospital bills contain errors such as unbundled codes or charges for services not rendered. If a patient receives a balance bill for an out-of-network service at this Critical Access Hospital, they may be protected under the No Surprises Act, which bans balance billing for emergency and non-emergency care at in-network facilities.