CMS Price Transparency Data

Hip or knee replacement (inpatient stay)

Facility: Adventist Health St Helena

Billing Code: 470 (MS-DRG)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 470
Insurance Median: $63,399
Cash Discount Price: $41,829
vs. Medicare Baseline: 4.51x Medicare

The contracted insurance negotiated median rate for a Hip or knee replacement (inpatient stay) at Adventist Health St Helena is $63,399. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $41,829. Compared to the federal Medicare reimbursement reference rate of $14,044.15, this hospital’s rate is 4.51x the Medicare baseline. Located in 10 Woodland Road, Saint Helena, CA.

Cash / Self-Pay

$41,829

Average discount available for prompt cash payment at this facility.

Insurance Median

$63,399

Median negotiated contract rate across all mapped commercial carriers.

Medicare Reference Rate

$14,044.15

Standard federal government reimbursement rate for this code.

Visual Cost Comparison vs. Medicare

Medicare Reference Baseline: $14,044.15 (100%)

Cash / Self-Pay: $41,829 (298%)

Insurance Median: $63,399 (451%)

Cash: $41,829 (298% of Medicare)

Ins. Median: $63,399 (451% of Medicare)

Understanding this gauge: We use the federal Medicare rate of $14,044.15 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 451% of the Medicare baseline (a markup of 351%). 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
Blue Shield Bh Mcr Adv	$19,803	141%
Blue Shield Mcr Adv	$19,803	141%
Tricare	$19,803	141%
UnitedHealthcare	$19,803 - $170,967	141%
Va Mcr - All Other Plans	$19,803	141%
Phcs-All Plans	$33,714	240%
Ah Employee Health Plan - All Plans	$35,645	254%
Magellan Mcare Ip Only	$38,761	276%
Va Medi-Cal	$41,968	299%
Blue Cross Blue Shield	$45,910 - $62,040	327%
Blue Shield Epn-All Other Plans	$50,659	361%
Aetna	$53,105	378%
Blue Shield Non-Epn	$53,489	381%
Healthnet-All Plans	$64,759	461%
Western Growers-All Plans	$77,338	551%
Interplan-All Plans	$88,517	630%
Kaiser Mcr Adv	$144,288	1027%
Kaiser-All Other Plans	$144,288	1027%
Coventry/First Health-All Plans	$167,314	1191%
Beech Street-All Plans	$195,200	1390%
Choicecare-All Plans	$195,200	1390%
Cigna	$195,200	1390%
Health Management Network-All Plans	$237,028	1688%
Galaxy Network-All Plans	$250,971	1787%
Three Rivers-All Plans	$250,971	1787%

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 $41,829.
Request and sign a "Waiver of Insurance Submission" to prevent automatic billing.
Verify MS-DRG Code matches exactly: 470.

Insurance In-Network Protection Plan

Contact your insurance company to confirm Adventist Health St Helena is fully in-network.
Ask your insurer if "Prior Authorization" is required for MS-DRG code 470.
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.