Office visit, established patient (20-29 min)
Facility: Lmh
Billing Code: 99213 (CPT)
- CPT Billing Code: 99213
- Insurance Median: $305
- Cash Discount Price: $113
- vs. Medicare Baseline: 3.20x 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 $95.19 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 320% of the Medicare baseline (a markup of 220%). 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 | $52 - $55 | 55% |
| Edw | $89 | 93% |
| Cigna | $251 - $308 | 264% |
| Aetna | $280 - $383 | 294% |
| UnitedHealthcare | $305 - $320 | 320% |
| Non Contracted | $352 - $369 | 370% |
| First Health | $409 - $429 | 430% |
Consumer Guidance & Cost Commentary
For this office visit code (99213) at Lmh in Lawrence, KS, the cash median price is $113.00, which is significantly lower than the facility's gross charge of $451.00. While the facility is a government-owned acute care hospital, patients with high-deductible plans may find paying cash directly more cost-effective than using insurance, as the negotiated rates for major payers like Cigna ($251–$308) and Aetna ($280–$383) often exceed the cash price. To maximize savings, patients should explicitly request "self-pay" or "prompt-pay" discounts before scheduling, as these upfront payment incentives can reduce the final bill by 20% to 50% by bypassing administrative claim processing costs.
The facility's pricing is also evaluated against Medicare benchmarks, where the allowed amount of $95.19 serves as the baseline for fair pricing. This code's gross charge is 3.2 times the Medicare rate, illustrating the typical markup found in commercial billing structures. It is important to note that while the No Surprises Act protects patients from balance billing for out-of-network services at in-network facilities, patients should still review their itemized bills carefully to ensure no unbundled codes or services not rendered have been charged. If a discrepancy is found, a formal written audit dispute should be sent to the billing supervisor rather than accepting a summary bill or settling verbally.