Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

BODY FLUID CELL COUNT

Facility

$14.00

Service Code	CPT 89051
Hospital Revenue Code	300
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$7.00
Rate for Payer: SELF PAY	$7.00

BODY FLUID CULTURE

Facility

$16.00

Service Code	CPT 87070
Hospital Revenue Code	300
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$8.00
Rate for Payer: SELF PAY	$8.00

BOLUS FEEDING SET WITH SINGLE

Facility

$85.28

Hospital Revenue Code	270
Min. Negotiated Rate	$42.64
Max. Negotiated Rate	$42.64
Rate for Payer: SELF PAY	$42.64

BONE CULTURE

Facility

$90.90

Service Code	CPT 87040
Hospital Revenue Code	300
Min. Negotiated Rate	$45.45
Max. Negotiated Rate	$45.45
Rate for Payer: SELF PAY	$45.45

Bone diseases and arthropathies with MCC

Facility

$112,000.00

Service Code	MSDRG 553
Min. Negotiated Rate	$62,443.10
Max. Negotiated Rate	$69,381.22
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$69,381.22
Rate for Payer: American Health Plans Medicare Advantage	$69,381.22
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$69,381.22
Rate for Payer: CIGNA Medicare Advantage	$69,381.22
Rate for Payer: HealthChoice Utah Medicare Advantage	$69,381.22
Rate for Payer: Humana Medicare Advantage	$69,381.22
Rate for Payer: Medicare	$69,381.22
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$69,381.22
Rate for Payer: MOLINA MEDICARE	$69,381.22
Rate for Payer: Pacific Source Medicare Advantage	$69,381.22
Rate for Payer: Select Health Medicare Advantage	$69,381.22
Rate for Payer: SELF PAY	$56,000.00
Rate for Payer: Tricare West Military	$62,443.10

Bone diseases and arthropathies without MCC

Facility

$86,400.00

Service Code	MSDRG 554
Min. Negotiated Rate	$41,788.22
Max. Negotiated Rate	$46,431.36
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$46,431.36
Rate for Payer: American Health Plans Medicare Advantage	$46,431.36
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$46,431.36
Rate for Payer: CIGNA Medicare Advantage	$46,431.36
Rate for Payer: HealthChoice Utah Medicare Advantage	$46,431.36
Rate for Payer: Humana Medicare Advantage	$46,431.36
Rate for Payer: Medicare	$46,431.36
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$46,431.36
Rate for Payer: MOLINA MEDICARE	$46,431.36
Rate for Payer: Pacific Source Medicare Advantage	$46,431.36
Rate for Payer: Select Health Medicare Advantage	$46,431.36
Rate for Payer: SELF PAY	$43,200.00
Rate for Payer: Tricare West Military	$41,788.22

BRAVA MOLDABLE RINGS

Facility

$76.80

Hospital Revenue Code	270
Min. Negotiated Rate	$38.40
Max. Negotiated Rate	$38.40
Rate for Payer: SELF PAY	$38.40

BRAVA MOLDABLE RINGS WP

Facility

$7.32

Hospital Revenue Code	270
Min. Negotiated Rate	$3.66
Max. Negotiated Rate	$3.66
Rate for Payer: SELF PAY	$3.66

Breast biopsy, local excision and other breast procedures with CC/MCC

Facility

$89,600.00

Service Code	MSDRG 584
Min. Negotiated Rate	$38,056.91
Max. Negotiated Rate	$42,285.46
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$42,285.46
Rate for Payer: American Health Plans Medicare Advantage	$42,285.46
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$42,285.46
Rate for Payer: CIGNA Medicare Advantage	$42,285.46
Rate for Payer: HealthChoice Utah Medicare Advantage	$42,285.46
Rate for Payer: Humana Medicare Advantage	$42,285.46
Rate for Payer: Medicare	$42,285.46
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$42,285.46
Rate for Payer: MOLINA MEDICARE	$42,285.46
Rate for Payer: Pacific Source Medicare Advantage	$42,285.46
Rate for Payer: Select Health Medicare Advantage	$42,285.46
Rate for Payer: SELF PAY	$44,800.00
Rate for Payer: Tricare West Military	$38,056.91

Breast biopsy, local excision and other breast procedures without CC/MCC

Facility

$89,600.00

Service Code	MSDRG 585
Min. Negotiated Rate	$38,056.91
Max. Negotiated Rate	$42,285.46
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$42,285.46
Rate for Payer: American Health Plans Medicare Advantage	$42,285.46
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$42,285.46
Rate for Payer: CIGNA Medicare Advantage	$42,285.46
Rate for Payer: HealthChoice Utah Medicare Advantage	$42,285.46
Rate for Payer: Humana Medicare Advantage	$42,285.46
Rate for Payer: Medicare	$42,285.46
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$42,285.46
Rate for Payer: MOLINA MEDICARE	$42,285.46
Rate for Payer: Pacific Source Medicare Advantage	$42,285.46
Rate for Payer: Select Health Medicare Advantage	$42,285.46
Rate for Payer: SELF PAY	$44,800.00
Rate for Payer: Tricare West Military	$38,056.91

Bronchitis and asthma with CC/MCC

Facility

$70,400.00

Service Code	MSDRG 202
Min. Negotiated Rate	$31,579.40
Max. Negotiated Rate	$35,088.22
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$35,088.22
Rate for Payer: American Health Plans Medicare Advantage	$35,088.22
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$35,088.22
Rate for Payer: CIGNA Medicare Advantage	$35,088.22
Rate for Payer: HealthChoice Utah Medicare Advantage	$35,088.22
Rate for Payer: Humana Medicare Advantage	$35,088.22
Rate for Payer: Medicare	$35,088.22
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$35,088.22
Rate for Payer: MOLINA MEDICARE	$35,088.22
Rate for Payer: Pacific Source Medicare Advantage	$35,088.22
Rate for Payer: Select Health Medicare Advantage	$35,088.22
Rate for Payer: SELF PAY	$35,200.00
Rate for Payer: Tricare West Military	$31,579.40

Bronchitis and asthma without CC/MCC

Facility

$54,400.00

Service Code	MSDRG 203
Min. Negotiated Rate	$20,811.69
Max. Negotiated Rate	$23,124.10
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$23,124.10
Rate for Payer: American Health Plans Medicare Advantage	$23,124.10
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$23,124.10
Rate for Payer: CIGNA Medicare Advantage	$23,124.10
Rate for Payer: HealthChoice Utah Medicare Advantage	$23,124.10
Rate for Payer: Humana Medicare Advantage	$23,124.10
Rate for Payer: Medicare	$23,124.10
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$23,124.10
Rate for Payer: MOLINA MEDICARE	$23,124.10
Rate for Payer: Pacific Source Medicare Advantage	$23,124.10
Rate for Payer: Select Health Medicare Advantage	$23,124.10
Rate for Payer: SELF PAY	$27,200.00
Rate for Payer: Tricare West Military	$20,811.69

BUBBLER ADAPTER

Facility

$1.44

Hospital Revenue Code	270
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$0.72
Rate for Payer: SELF PAY	$0.72

BUBBLER (PREFILLED)

Facility

$3.32

Hospital Revenue Code	270
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$1.66
Rate for Payer: SELF PAY	$1.66

BUBBLER (PREFILLED) WP

Facility

$3.32

Hospital Revenue Code	270
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$1.66
Rate for Payer: SELF PAY	$1.66

BUN

Facility

$3.95

Service Code	CPT 84520
Hospital Revenue Code	300
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$1.98
Rate for Payer: SELF PAY	$1.98

CALCIUM

Facility

$3.16

Service Code	CPT 82310
Hospital Revenue Code	300
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$1.58
Rate for Payer: SELF PAY	$1.58

CALCIUM IONIZED

Facility

$38.00

Service Code	CPT 82330
Hospital Revenue Code	300
Min. Negotiated Rate	$19.00
Max. Negotiated Rate	$19.00
Rate for Payer: SELF PAY	$19.00

CAMPYLOBACTER ANTIGEN

Facility

$40.00

Service Code	CPT 87449
Hospital Revenue Code	300
Min. Negotiated Rate	$20.00
Max. Negotiated Rate	$20.00
Rate for Payer: SELF PAY	$20.00

CANNULA PED/SMALL LOW FLOW VAP

Facility

$35.46

Hospital Revenue Code	270
Min. Negotiated Rate	$17.73
Max. Negotiated Rate	$17.73
Rate for Payer: SELF PAY	$17.73

CANNULA PREMATRUE LOW FLOW VAP

Facility

$44.28

Hospital Revenue Code	270
Min. Negotiated Rate	$22.14
Max. Negotiated Rate	$22.14
Rate for Payer: SELF PAY	$22.14

Canopy Bed

Facility

$60.00

Hospital Revenue Code	290
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$30.00
Rate for Payer: SELF PAY	$30.00

CARBAMAZEPINE TEGRETOL

Facility

$79.00

Service Code	CPT 80156
Hospital Revenue Code	300
Min. Negotiated Rate	$39.50
Max. Negotiated Rate	$39.50
Rate for Payer: SELF PAY	$39.50

Cardiac arrest, unexplained with CC

Facility

$54,400.00

Service Code	MSDRG 297
Min. Negotiated Rate	$22,102.36
Max. Negotiated Rate	$24,558.18
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$24,558.18
Rate for Payer: American Health Plans Medicare Advantage	$24,558.18
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$24,558.18
Rate for Payer: CIGNA Medicare Advantage	$24,558.18
Rate for Payer: HealthChoice Utah Medicare Advantage	$24,558.18
Rate for Payer: Humana Medicare Advantage	$24,558.18
Rate for Payer: Medicare	$24,558.18
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$24,558.18
Rate for Payer: MOLINA MEDICARE	$24,558.18
Rate for Payer: Pacific Source Medicare Advantage	$24,558.18
Rate for Payer: Select Health Medicare Advantage	$24,558.18
Rate for Payer: SELF PAY	$27,200.00
Rate for Payer: Tricare West Military	$22,102.36

Cardiac arrest, unexplained with MCC

Facility

$67,200.00

Service Code	MSDRG 296
Min. Negotiated Rate	$31,185.36
Max. Negotiated Rate	$34,650.40
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$34,650.40
Rate for Payer: American Health Plans Medicare Advantage	$34,650.40
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$34,650.40
Rate for Payer: CIGNA Medicare Advantage	$34,650.40
Rate for Payer: HealthChoice Utah Medicare Advantage	$34,650.40
Rate for Payer: Humana Medicare Advantage	$34,650.40
Rate for Payer: Medicare	$34,650.40
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$34,650.40
Rate for Payer: MOLINA MEDICARE	$34,650.40
Rate for Payer: Pacific Source Medicare Advantage	$34,650.40
Rate for Payer: Select Health Medicare Advantage	$34,650.40
Rate for Payer: SELF PAY	$33,600.00
Rate for Payer: Tricare West Military	$31,185.36

Know your out-of-pocket cost for care.

All Charges