CMS Price Transparency Data

Physical therapy (gait training)

Facility: Stoughton Hospital

Billing Code: 97116 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 97116
Insurance Median: $111
Cash Discount Price: $105
vs. Medicare Baseline: 3.82x Medicare

The contracted insurance negotiated median rate for a Physical therapy (gait training) at Stoughton Hospital is $111. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $105. Compared to the federal Medicare reimbursement reference rate of $29.06, this hospital’s rate is 3.82x the Medicare baseline. Located in 900 Ridge St, Stoughton, WI.

Cash / Self-Pay

$105

Average discount available for prompt cash payment at this facility.

Insurance Median

$111

Median negotiated contract rate across all mapped commercial carriers.

Medicare Reference Rate

$29.06

Standard federal government reimbursement rate for this code.

Visual Cost Comparison vs. Medicare

Medicare Reference Baseline: $29.06 (100%)

Cash / Self-Pay: $105 (361%)

Insurance Median: $111 (382%)

Cash: $105 (361% of Medicare)

Ins. Median: $111 (382% of 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 382% of the Medicare baseline (a markup of 282%). Patients with high-deductible plans or out-of-network benefits may face excessive out-of-pocket costs.

Consult Patient Advocate

Out-of-Pocket Cost Estimator

Estimate whether it is more economical to use your insurance or pay the upfront self-pay cash rate.

Billing Status

Remaining Deductible ($)

Your Coinsurance Rate (%)

Input your details and click calculate to compare out-of-pocket costs.

Commercial Insurance Negotiated Rates

Negotiated contract ranges established by major commercial carriers at this facility.

Carrier / Plan Group	Contract Rate Range	vs. Medicare Reference
Medicaid / KanCare	$36	124%
Tricare	$45	155%
Healthnet Mcr Adv - All Plans	$51	175%
Dean Health Insurance Med Adv	$53	182%
Humana	$53 - $172	182%
Quartz Mcr Adv	$53	182%
Security Health/First Health - All Plans	$53	182%
Quartz Health Solutions - All Other Lans	$54	186%
Aetna	$57 - $162	196%
UnitedHealthcare	$84 - $153	289%
Alliance - All Plans	$111	382%
Dean Health Insurance Epo	$118	406%
Dean Health Insurance Comm - All Other Plans	$143	492%
Geha - All Plans	$143	492%
Cigna	$153	526%
Wisconsin Ppo Ppa Direct - All Plans	$153	526%
Blue Cross Blue Shield	$166	571%
Wps - All Plans	$172	592%

Self-Pay Upfront Cash Action Plan

Request a "Self-Pay classification" with the billing desk before receiving care.
Ask for a written "Prompt-Pay Discount" agreement quoting the price of $105.
Request and sign a "Waiver of Insurance Submission" to prevent automatic billing.
Verify CPT Code matches exactly: 97116.

Insurance In-Network Protection Plan

Contact your insurance company to confirm Stoughton Hospital is fully in-network.
Ask your insurer if "Prior Authorization" is required for CPT code 97116.
Confirm the specific physician or imaging center is also in-network (not just the hospital building).
Audit your Explanation of Benefits (EOB) against the final itemized hospital invoice.