This was in California (greater Bay Area), and the hospital was in network, but some of the ER physicians ended up not being (not the source of this part of the bill). I had a high deductible plan (10k IIRC?) so that I could stock away cash in an HSA every month. I've since switched to a much lower deductible plan in case I needed to go to the ER again, but then I also to another county and have gotten much more reasonable bills at the hospital near me.