Office visit, established patient (20-29 min)
Facility: Hiawatha Community Hospital
Billing Code: 99213 (CPT)
- CPT Billing Code: 99213
- Insurance Median: $221
- Cash Discount Price: $259
- vs. Medicare Baseline: 2.32x 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 232% of the Medicare baseline (a markup of 132%). 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 |
|---|---|---|
| Aetna | $64 - $257 | 67% |
| UnitedHealthcare | $64 - $262 | 67% |
| Humana | $64 - $257 | 67% |
| Ambetter / Centene | $76 - $270 | 80% |
| Blue Cross Blue Shield | $127 - $133 | 133% |
| Centrus Health Direct - All Plans | $129 - $229 | 136% |
| Oscar - All Plans | $129 - $229 | 136% |
| Preferred Hlth - All Plans | $155 - $274 | 163% |
| Wppa Providrs Care - All Plans | $163 - $290 | 171% |
| Cigna | $163 - $290 | 171% |
| Multiplan - All Plans | $167 - $296 | 175% |
| Midlands Choice - All Plans | $167 - $296 | 175% |
| Healthy Blue Mcaid - All Plans | $172 - $305 | 181% |
Consumer Guidance & Cost Commentary
For this office visit at Hiawatha Community Hospital, the cash price of $259.00 is identical to the facility's median negotiated rate of $226.00 and the state average of $259.00. While commercial insurance plans like Aetna and UnitedHealthcare negotiate rates ranging from $64 to $262, these figures often exceed the cash price, meaning patients with high-deductible plans might save money by paying out-of-pocket. It is important to note that while the No Surprises Act protects patients from balance billing for emergency services at in-network facilities, non-emergency services may still incur unexpected costs if out-of-network providers are involved. Consumers should always verify their specific plan details and ask the hospital directly about "self-pay" or "prompt-pay" discounts before scheduling, as these upfront incentives can significantly reduce the final amount owed.
The facility's pricing structure is anchored by a Medicare benchmark of $95.19, which serves as the objective baseline for evaluating commercial rate markups. Although the gross chargemaster listed is $259.00, the actual median paid amount is $226.00, reflecting the negotiated caps that protect in-network members. Patients should be aware that hospitals often issue summary bills that obscure individual line items, so requesting a full itemized audit is a critical step to identify errors, unbundled codes, or services not rendered. By comparing the facility's rates directly to the Medicare benchmark rather than the inflated chargemaster list, consumers can better understand the true cost of care and ensure they are not overpaying for services that should be covered at a fair market value.