CMS Price Transparency Data

Office visit, established patient (20-29 min)

Facility: Kenmore Mercy Hospital

Billing Code: 99213 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 99213
Insurance Median: $81
Cash Discount Price: $190
vs. Medicare Baseline: 0.85x Medicare

The contracted insurance negotiated median rate for a Office visit, established patient (20-29 min) at Kenmore Mercy Hospital is $81. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $190. Compared to the federal Medicare reimbursement reference rate of $95.19, this hospital’s rate is 0.85x the Medicare baseline. Located in 2950 Elmwood Avenue, Kenmore, NY.

Cash / Self-Pay

$190

Average discount available for prompt cash payment at this facility.

Insurance Median

$81

Median negotiated contract rate across all mapped commercial carriers.

Medicare Reference Rate

$95.19

Standard federal government reimbursement rate for this code.

Visual Cost Comparison vs. Medicare

Medicare Reference Baseline: $95.19 (100%)

Cash / Self-Pay: $190 (200%)

Insurance Median: $81 (85%)

Cash: $190 (200% of Medicare)

Ins. Median: $81 (85% of 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.

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
Blue Cross Blue Shield	$37 - $106	39%
Beacon Essential [350122]	$57 - $76	60%
Medicaid / KanCare	$57 - $88	60%
Federal Workers Compensation [500100]	$63 - $71	66%
Medicare (plans)	$63 - $92	66%
Hospice [550001]	$63 - $88	66%
UnitedHealthcare	$66 - $88	69%
Univera Healthcare [100169]	$71 - $98	75%
No Fault [114001]	$71	75%
Univera Healthcare Essential [100170]	$71	75%
UPMC Health Plan [100181]	$74	78%
Beacon Health Options [100023]	$76	80%
Fidelis Essential [100163]	$79 - $105	83%
Tuscarora Nation [550120]	$80	84%
Amerigroup [350102]	$80	84%
Excellus Rochester McD [350117]	$80	84%
Independent Health Essential [100166]	$80	84%
Crime Victims [100176]	$80	84%
Vna Option Mltc [350110]	$80	84%
Mvp Healthcare [100168]	$81	85%
Covid19 Hrsa [45013]	$88	92%
Magnacare [100142]	$88	92%
Seneca Nation [450119]	$88	92%
Fallon Health [450115]	$88	92%
Catholic Health Life Pace [400005]	$88	92%
Cigna	$88 - $127	92%
Aetna	$88	92%
Meritain [100063]	$88	92%
Humana	$88	92%
Tricare	$88	92%
VA Veterans Affairs [700001]	$88	92%
Champ VA [700002]	$88	92%
Fidelis Dual Advantage [450120]	$92	97%
Wellcare Fidelis Dual [450451]	$92	97%
Iha First Choice [800001]	$95	100%
Independent Health [100165]	$95	100%
Wellcare [450129]	$96	101%
Ghi [100153]	$96	101%
Fidelis Exchange [100164]	$105	110%
Molina Essential [100167]	$180	189%

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 $190.
Request and sign a "Waiver of Insurance Submission" to prevent automatic billing.
Verify CPT Code matches exactly: 99213.

Insurance In-Network Protection Plan

Contact your insurance company to confirm Kenmore Mercy Hospital is fully in-network.
Ask your insurer if "Prior Authorization" is required for CPT code 99213.
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.