That’s the insanity. You are the same person, same procedure, everything same but somehow the hospital can reduce its bill from 49000 to 9000. That is just not normal for a business like a hospital where they have a ton of fixed costs (unlike a software company where delivery of their product often costs close to zero so they can easily give rebates). This seems to indicate that the 49k is an insanely high price with very high profit margin.