CMS Price Transparency Data

Hip or knee replacement (inpatient stay)

Facility: Saint Michael's Medical Center

Billing Code: 470 (MS-DRG)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 470
Insurance Median: $28,404
Cash Discount Price: $25,375
vs. Medicare Baseline: 2.02x Medicare

The contracted insurance negotiated median rate for a Hip or knee replacement (inpatient stay) at Saint Michael's Medical Center is $28,404. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $25,375. Compared to the federal Medicare reimbursement reference rate of $14,044.15, this hospital’s rate is 2.02x the Medicare baseline. Located in 111 Central Avenue, Newark, NJ.

Cash / Self-Pay

$25,375

Average discount available for prompt cash payment at this facility.

Insurance Median

$28,404

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: $25,375 (181%)

Insurance Median: $28,404 (202%)

Cash: $25,375 (181% of Medicare)

Ins. Median: $28,404 (202% 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 202% of the Medicare baseline (a markup of 102%). 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
Horizon	$12,421 - $41,030	88%
Amerihealth	$20,824	148%
Wellpoint Amerigroup	$20,824	148%
Ubh	$20,824	148%
Aetna	$20,824 - $45,929	148%
UnitedHealthcare	$20,824 - $33,925	148%
Wellcare	$21,449 - $34,256	153%
Clover Health	$21,657	154%
Medicare (plans)	$25,375	181%
Humana	$25,375	181%
Curana	$26,644	190%
Tricare	$29,060	207%
Naphcare	$32,277	230%
Cigna	$32,676	233%
Employer Direct Healthcare	$32,988	235%
Fairprice Healthcare Holdings - Fphh	$40,600	289%
Coventry	$43,138	307%

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 $25,375.
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 Saint Michael's Medical Center 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.