Physical therapy (gait training)
Facility: Clay County Medical Center
Billing Code: 97116 (CPT)
- CPT Billing Code: 97116
- Insurance Median: $67
- Cash Discount Price: $70
- vs. Medicare Baseline: 2.31x 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 231% of the Medicare baseline (a markup of 131%). 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 |
|---|---|---|
| Wppa/Providrs Care- All Plans | $65 | 224% |
| Aetna | $65 | 224% |
| Multiplan- All Plans | $67 | 231% |
| UnitedHealthcare | $67 | 231% |
| Health Partners - All Plans | $67 | 231% |
Consumer Guidance & Cost Commentary
For the CPT code 97116, representing physical therapy gait training, Clay County Medical Center in Clay Center, KS, lists a cash median price of $70.00. This cash rate is identical to the facility's negotiated rates across five major payers, including Aetna, UnitedHealthcare, and Wppa/Providrs Care, all of which pay $65.00 to $67.00 depending on the specific plan. While the facility's negotiated rates are slightly higher than the cash price, patients with high-deductible plans may find paying out-of-pocket cheaper if their insurance allowed amount exceeds the cash rate. It is important to note that the facility is a Critical Access Hospital owned by the local government, and patients should explicitly ask about "self-pay" or "prompt-pay" discounts before scheduling to ensure they are not billed the full negotiated amount.
The facility's pricing structure is significantly lower than the national benchmark for this service. The Medicare amount for this procedure is $29.06, and the facility's cash rate of $70.00 represents a markup of 2.3 times the Medicare rate. This aligns with the general healthcare principle that commercial rates often exceed Medicare benchmarks due to administrative costs and contract dynamics. Because the facility is a Critical Access Hospital, patients should be aware of federal protections against balance billing for out-of-network services at in-network facilities under the No Surprises Act. If a patient receives an unexpected bill, they should request an itemized audit to verify that no unbundled codes or services not rendered are included, ensuring the final charge matches the transparent data provided.