Physical therapy (gait training)
Facility: Smith County Memorial Hospital
Billing Code: 97116 (CPT)
- CPT Billing Code: 97116
- Insurance Median: $65
- Cash Discount Price: $69
- vs. Medicare Baseline: 2.24x 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 224% of the Medicare baseline (a markup of 124%). 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% |
| Medicaid / KanCare | $48 - $69 | 165% |
| Multiplan-All Plans | $62 | 213% |
| Wppa-All Plans | $65 | 224% |
| Health Partners Of Ks Ppo-All Plans | $66 | 227% |
| UnitedHealthcare | $66 | 227% |
| Midlands Choice-All Plans | $66 | 227% |
Consumer Guidance & Cost Commentary
For the CPT code 97116, representing physical therapy gait training, Smith County Memorial Hospital in Smith Center, KS, lists a gross charge of $69.00. While the facility's cash median is also $69.00, the actual amount typically paid by insurance is lower, with a median negotiated rate of $65.00 across seven payers. It is important to note that cash payments can sometimes be more cost-effective for patients with high-deductible plans if the insurance negotiated rate exceeds the cash price, though in this specific case, the cash rate matches the gross charge. Patients should verify their specific plan's deductible status before scheduling, as paying out-of-pocket may result in higher out-of-pocket costs if the deductible has not yet been met.
When evaluating the cost of this service, it is crucial to compare rates against the Medicare benchmark rather than the hospital's inflated list price. The Medicare amount for this procedure is $29.06, which serves as the objective baseline for fair pricing. Commercial negotiated rates often average 200% to 300% of the Medicare rate, whereas fair pricing is typically defined as 120% to 150% of this benchmark. Additionally, patients should inquire about "self-pay" or "prompt-pay" discounts, which can range from 20% to 50% off the billed amount when paying in full upfront, bypassing the administrative costs associated with insurance claims processing.