PT Evaluation (Moderate Complexity) Cost in Illinois
Pt eval mod complex 30 min
$96.80Illinois physician fee2026 Medicare office rate- ✓Your ZIP's wage-adjusted hospital and surgery centre rates
- ✓Five nearby hospitals by name, with CMS star ratings
- ✓The add-on codes that typically land on the bill
- ✓A word-for-word script for asking for a good-faith estimate
- ✓A private link you can reopen and share
- ✓Everything in the Premium report
- ✓15 nearby hospitals instead of five
- ✓Filled good-faith-estimate request letter
- ✓Bill-negotiation letter
- ✓Printable PDF download
Illinois Medicare physician rate (2026)
-1.1% vs nationalAverage of 4 localities. Office range $94.04–$99.73.
Your ZIP in Illinois
Enter a ZIP code to see which Illinois locality applies to you, whether Chicago proper, the suburban collar counties, the Metro East near St. Louis, or downstate cities like Springfield, Peoria, and Champaign.
What pt evaluation (moderate complexity) costs at hospitals near you
Everything above is a national average. The hospital you pick in Illinois moves the bill more than anything else you control.
Rates for your ZIP, 5 named hospitals with CMS ratings, the add-on codes, and the scheduler script.
One-off payment, no account and no subscription. You get a private link and an email. No medical records and no insurance card, ever.
What these numbers are
Every figure on this page is a 2026 Medicare allowed amount: the physician line comes from the Physician Fee Schedule adjusted by geographic practice-cost indices, and the facility totals come from the CMS hospital outpatient (OPPS) and ambulatory surgery centre rates. None of them is a hospital chargemaster price, your insurer's contracted rate, or a quote. Anesthesia, pathology, imaging reads and follow-up care are billed under their own codes when they apply, and an inpatient stay is paid a different way again.
National vs Illinois
Where Illinois ranks for this CPT
CPT 97162 by Illinois locality
| Locality | Office |
|---|---|
| suburban chicago | $99.73 |
| chicago | $98.89 |
| east st. louis | $94.52 |
| rest of illinois | $94.04 |
PE GPCI ranges from 0.913 to 1.027 in Illinois. That index is why the same CPT is not one price statewide.
PT Evaluation (Moderate Complexity) and how Illinois is priced
Illinois uses one of the more detailed locality maps in the Midwest: Chicago has its own locality, the suburban collar counties are priced separately, the East St. Louis area carries its own locality tied to the St. Louis market, and the rest of the state shares a fourth. Approved amounts step down noticeably from the city and suburbs to downstate, so the same procedure prices differently in Chicago, Naperville, Belleville, and Springfield. This four-way split makes Illinois one of the states where a ZIP-level check genuinely changes the answer. Downstate rates align more closely with neighboring rural states than with Chicagoland.
Chicago is one of the country's great medical hubs, with multiple academic medical centers and deep specialist supply, and its suburbs support large competing systems of their own. Downstate Illinois is a different market: smaller cities like Peoria, Springfield, and Champaign serve wide rural areas, and the Metro East suburbs orient toward St. Louis providers. Where you sit on that map shapes both price and choice.
This procedure: This is the moderate-complexity initial physical therapy evaluation, used when your situation has real complicating factors: one or more health conditions affecting rehab, an evolving rather than stable presentation, or changed function in daily activities. A typical example is knee rehab in someone with diabetes and prior joint surgery. The PT takes a more extensive history and examines more body systems than in a simple case, usually across a 45 to 75 minute appointment that often ends with the first treatment.
What Is PT Evaluation (Moderate Complexity)?
This is the moderate-complexity initial physical therapy evaluation, used when your situation has real complicating factors: one or more health conditions affecting rehab, an evolving rather than stable presentation, or changed function in daily activities. A typical example is knee rehab in someone with diabetes and prior joint surgery. The PT takes a more extensive history and examines more body systems than in a simple case, usually across a 45 to 75 minute appointment that often ends with the first treatment.
What Affects the Cost
- –As the middle evaluation tier, some commercial payers price it above the low-complexity code, while Medicare pays all three tiers equally.
- –Complicated patients tend to need longer courses of care, so the evaluation tier itself signals a larger total spend ahead.
- –First-day treatment units bill in addition to the evaluation.
- –Comorbidities can mean coordination with physicians or extra documentation, occasionally generating separate visits elsewhere.
- –Clinic ownership matters as always: hospital-affiliated clinics add facility fees to every encounter including this one.
Questions to Ask Before Booking
- 1.What makes my case moderate complexity, and does that tier change what I pay under my plan?
- 2.Given my other health conditions, how long a course of therapy should I budget for?
- 3.Will you treat me on evaluation day, and what will that first combined visit cost?
- 4.Does my insurer require a referral or pre-authorization before this evaluation?
- 5.How will you coordinate with my physician, and does that generate any separate charges?
Other featured procedures in Illinois
PT Evaluation (Moderate Complexity) in other states
PT Evaluation (Moderate Complexity) in Illinois: questions
The 2026 Medicare physician office rate for CPT 97162 averages $96.80 across 4 Illinois localities, from $94.04 in REST OF ILLINOIS to $99.73 in SUBURBAN CHICAGO. The hospital physician rate averages $96.80. Enter a ZIP for the exact locality.
Yes. CMS splits Illinois into 4 payment localities. For this CPT the office physician fee spans $5.69 from the lowest to highest locality. Enter a ZIP code to see which Illinois locality applies to you, whether Chicago proper, the suburban collar counties, the Metro East near St. Louis, or downstate cities like Springfield, Peoria, and Champaign.
After the Part B deductible, coinsurance is usually 20% of the allowed amount: about $19 for the office physician line or $19 for the hospital physician line in Illinois. Medigap may cover that 20%. This is not the hospital facility fee.
No. $96.80 is the Medicare physician allowed amount for CPT 97162. Anesthesia, facility fees, implants, and other CPT codes billed the same day are extra. Illinois ranks #25 of 51 states on this physician line (within 2% of the national office rate of $97.86).