Much of this stems from USG/medicare practices that have long encouraged high "rack rates" for care. Back when Medicare started getting more aggressive on their reimbursement rates (i.e., not paying the total cost) they recognized that many hospitals were doing Medicare patients at a loss, so they set up a kind of slush fund from leftover budget allocations that could be used to make up for some of those losses. At the end of the year, the hospitals would submit a claim to Medicare for those losses, and Medicare would split up the slush fund between the various claimants so that all got an extra few percent back. It didn't take long for the more savvy hospitals to boost their list prices to increase this apparent "loss" and get a bigger claim. As those who self pay for these procedures find, normal range charges are available for those who plan ahead and can use rates negotiated by their surgeons. The only ones who are really charged these rack rates are the uninsured who use the emergeny rooms as their PCP and skip on the bills or those unfortunates between jobs and without insurance who get into accidents and go into bankrupcy over the inflated rack rates (but they don't have any lobbying power, so don't really count to the system.)