CMS Price Transparency Data

Hip or knee replacement (inpatient stay)

Facility: Down East Community Hospital

Billing Code: 470 (MS-DRG)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 470
Insurance Median: $49,591
Cash Discount Price: $44,730
vs. Medicare Baseline: 3.53x Medicare

The contracted insurance negotiated median rate for a Hip or knee replacement (inpatient stay) at Down East Community Hospital is $49,591. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $44,730. Compared to the federal Medicare reimbursement reference rate of $14,044.15, this hospital’s rate is 3.53x the Medicare baseline. Located in 11 Hospital Drive, Machias, ME.

Cash / Self-Pay

$44,730

Average discount available for prompt cash payment at this facility.

Insurance Median

$49,591

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: $44,730 (318%)

Insurance Median: $49,591 (353%)

Cash: $44,730 (318% of Medicare)

Ins. Median: $49,591 (353% 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 353% of the Medicare baseline (a markup of 253%). 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 Cross Blue Shield	$26,242 - $48,129	187%
Humana	$26,242	187%
Wellcare	$26,242	187%
Partners Direct Health	$29,820	212%
Community Health Options	$49,382	352%
Aetna	$49,799	355%
UnitedHealthcare	$51,290	365%
Martins Point	$53,676	382%
Patients Advocates	$53,676	382%
Cigna	$53,795	383%
Harvard Pilgrim	$54,571	389%

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 $44,730.
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 Down East Community Hospital 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.