Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

Cholecystectomy with C.D.E. with CC

Facility

$70,400.00

Service Code	MSDRG 412
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

Cholecystectomy with C.D.E. with MCC

Facility

$70,400.00

Service Code	MSDRG 411
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

Cholecystectomy with C.D.E. without CC/MCC

Facility

$70,400.00

Service Code	MSDRG 413
Min. Negotiated Rate	$30,972.26
Max. Negotiated Rate	$34,413.62
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$34,413.62
Rate for Payer: American Health Plans Medicare Advantage	$34,413.62
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$34,413.62
Rate for Payer: CIGNA Medicare Advantage	$34,413.62
Rate for Payer: HealthChoice Utah Medicare Advantage	$34,413.62
Rate for Payer: Humana Medicare Advantage	$34,413.62
Rate for Payer: Medicare	$34,413.62
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$34,413.62
Rate for Payer: MOLINA MEDICARE	$34,413.62
Rate for Payer: Pacific Source Medicare Advantage	$34,413.62
Rate for Payer: Select Health Medicare Advantage	$34,413.62
Rate for Payer: SELF PAY	$35,200.00
Rate for Payer: Tricare West Military	$30,972.26

Chronic obstructive pulmonary disease with CC

Facility

$60,800.00

Service Code	MSDRG 191
Min. Negotiated Rate	$24,374.11
Max. Negotiated Rate	$27,082.35
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$27,082.35
Rate for Payer: American Health Plans Medicare Advantage	$27,082.35
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$27,082.35
Rate for Payer: CIGNA Medicare Advantage	$27,082.35
Rate for Payer: HealthChoice Utah Medicare Advantage	$27,082.35
Rate for Payer: Humana Medicare Advantage	$27,082.35
Rate for Payer: Medicare	$27,082.35
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$27,082.35
Rate for Payer: MOLINA MEDICARE	$27,082.35
Rate for Payer: Pacific Source Medicare Advantage	$27,082.35
Rate for Payer: Select Health Medicare Advantage	$27,082.35
Rate for Payer: SELF PAY	$30,400.00
Rate for Payer: Tricare West Military	$24,374.11

Chronic obstructive pulmonary disease with MCC

Facility

$57,600.00

Service Code	MSDRG 190
Min. Negotiated Rate	$25,729.13
Max. Negotiated Rate	$28,587.92
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$28,587.92
Rate for Payer: American Health Plans Medicare Advantage	$28,587.92
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$28,587.92
Rate for Payer: CIGNA Medicare Advantage	$28,587.92
Rate for Payer: HealthChoice Utah Medicare Advantage	$28,587.92
Rate for Payer: Humana Medicare Advantage	$28,587.92
Rate for Payer: Medicare	$28,587.92
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$28,587.92
Rate for Payer: MOLINA MEDICARE	$28,587.92
Rate for Payer: Pacific Source Medicare Advantage	$28,587.92
Rate for Payer: Select Health Medicare Advantage	$28,587.92
Rate for Payer: SELF PAY	$28,800.00
Rate for Payer: Tricare West Military	$25,729.13

Chronic obstructive pulmonary disease without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 192
Min. Negotiated Rate	$18,346.93
Max. Negotiated Rate	$20,385.48
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$20,385.48
Rate for Payer: American Health Plans Medicare Advantage	$20,385.48
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$20,385.48
Rate for Payer: CIGNA Medicare Advantage	$20,385.48
Rate for Payer: HealthChoice Utah Medicare Advantage	$20,385.48
Rate for Payer: Humana Medicare Advantage	$20,385.48
Rate for Payer: Medicare	$20,385.48
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$20,385.48
Rate for Payer: MOLINA MEDICARE	$20,385.48
Rate for Payer: Pacific Source Medicare Advantage	$20,385.48
Rate for Payer: Select Health Medicare Advantage	$20,385.48
Rate for Payer: SELF PAY	$25,600.00
Rate for Payer: Tricare West Military	$18,346.93

CIRCUIT PED WIRE

Facility

$12.38

Hospital Revenue Code	270
Min. Negotiated Rate	$6.19
Max. Negotiated Rate	$6.19
Rate for Payer: SELF PAY	$6.19

Circulatory disorders except AMI, with cardiac catheterization with MCC

Facility

$112,000.00

Service Code	MSDRG 286
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

Circulatory disorders except AMI, with cardiac catheterization without MCC

Facility

$112,000.00

Service Code	MSDRG 287
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

Cirrhosis and alcoholic hepatitis with CC

Facility

$60,800.00

Service Code	MSDRG 433
Min. Negotiated Rate	$24,374.11
Max. Negotiated Rate	$27,082.35
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$27,082.35
Rate for Payer: American Health Plans Medicare Advantage	$27,082.35
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$27,082.35
Rate for Payer: CIGNA Medicare Advantage	$27,082.35
Rate for Payer: HealthChoice Utah Medicare Advantage	$27,082.35
Rate for Payer: Humana Medicare Advantage	$27,082.35
Rate for Payer: Medicare	$27,082.35
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$27,082.35
Rate for Payer: MOLINA MEDICARE	$27,082.35
Rate for Payer: Pacific Source Medicare Advantage	$27,082.35
Rate for Payer: Select Health Medicare Advantage	$27,082.35
Rate for Payer: SELF PAY	$30,400.00
Rate for Payer: Tricare West Military	$24,374.11

Cirrhosis and alcoholic hepatitis with MCC

Facility

$64,000.00

Service Code	MSDRG 432
Min. Negotiated Rate	$32,186.55
Max. Negotiated Rate	$35,762.83
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$35,762.83
Rate for Payer: American Health Plans Medicare Advantage	$35,762.83
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$35,762.83
Rate for Payer: CIGNA Medicare Advantage	$35,762.83
Rate for Payer: HealthChoice Utah Medicare Advantage	$35,762.83
Rate for Payer: Humana Medicare Advantage	$35,762.83
Rate for Payer: Medicare	$35,762.83
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$35,762.83
Rate for Payer: MOLINA MEDICARE	$35,762.83
Rate for Payer: Pacific Source Medicare Advantage	$35,762.83
Rate for Payer: Select Health Medicare Advantage	$35,762.83
Rate for Payer: SELF PAY	$32,000.00
Rate for Payer: Tricare West Military	$32,186.55

Cirrhosis and alcoholic hepatitis without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 434
Min. Negotiated Rate	$18,346.93
Max. Negotiated Rate	$20,385.48
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$20,385.48
Rate for Payer: American Health Plans Medicare Advantage	$20,385.48
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$20,385.48
Rate for Payer: CIGNA Medicare Advantage	$20,385.48
Rate for Payer: HealthChoice Utah Medicare Advantage	$20,385.48
Rate for Payer: Humana Medicare Advantage	$20,385.48
Rate for Payer: Medicare	$20,385.48
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$20,385.48
Rate for Payer: MOLINA MEDICARE	$20,385.48
Rate for Payer: Pacific Source Medicare Advantage	$20,385.48
Rate for Payer: Select Health Medicare Advantage	$20,385.48
Rate for Payer: SELF PAY	$25,600.00
Rate for Payer: Tricare West Military	$18,346.93

Facility

$5.35

Service Code	CPT 82435
Hospital Revenue Code	300
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$2.67
Rate for Payer: SELF PAY	$2.67

Clave Connector Multidose Vial

Facility

$3.78

Hospital Revenue Code	270
Min. Negotiated Rate	$1.89
Max. Negotiated Rate	$1.89
Rate for Payer: SELF PAY	$1.89

Clinatron Rite Hite

Facility

$174.00

Hospital Revenue Code	290
Min. Negotiated Rate	$87.00
Max. Negotiated Rate	$87.00
Rate for Payer: SELF PAY	$87.00

CLOG ZAPPER

Facility

$60.34

Hospital Revenue Code	270
Min. Negotiated Rate	$30.17
Max. Negotiated Rate	$30.17
Rate for Payer: SELF PAY	$30.17

CLONAZEPAM

Facility

$185.00

Service Code	CPT 80299
Hospital Revenue Code	300
Min. Negotiated Rate	$92.50
Max. Negotiated Rate	$92.50
Rate for Payer: SELF PAY	$92.50

CMP

Facility

$12.15

Service Code	CPT 80053
Hospital Revenue Code	300
Min. Negotiated Rate	$6.08
Max. Negotiated Rate	$6.08
Rate for Payer: SELF PAY	$6.08

CO2 TUBING FILTER & ADAPTER

Facility

$13.00

Hospital Revenue Code	270
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$6.50
Rate for Payer: SELF PAY	$6.50

Coagulation disorders

Facility

$60,800.00

Service Code	MSDRG 813
Min. Negotiated Rate	$24,374.11
Max. Negotiated Rate	$27,082.35
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$27,082.35
Rate for Payer: American Health Plans Medicare Advantage	$27,082.35
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$27,082.35
Rate for Payer: CIGNA Medicare Advantage	$27,082.35
Rate for Payer: HealthChoice Utah Medicare Advantage	$27,082.35
Rate for Payer: Humana Medicare Advantage	$27,082.35
Rate for Payer: Medicare	$27,082.35
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$27,082.35
Rate for Payer: MOLINA MEDICARE	$27,082.35
Rate for Payer: Pacific Source Medicare Advantage	$27,082.35
Rate for Payer: Select Health Medicare Advantage	$27,082.35
Rate for Payer: SELF PAY	$30,400.00
Rate for Payer: Tricare West Military	$24,374.11

COBAN 1"

Facility

$1.60

Hospital Revenue Code	270
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$0.80
Rate for Payer: SELF PAY	$0.80

COBAN 1" WP

Facility

$1.60

Hospital Revenue Code	270
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$0.80
Rate for Payer: SELF PAY	$0.80

COBAN 2"

Facility

$2.48

Hospital Revenue Code	270
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$1.24
Rate for Payer: SELF PAY	$1.24

COBAN 2 LAYER SYSTEM COMPRESS

Facility

$28.76

Hospital Revenue Code	270
Min. Negotiated Rate	$14.38
Max. Negotiated Rate	$14.38
Rate for Payer: SELF PAY	$14.38

COBAN 2" WP

Facility

$2.48

Hospital Revenue Code	270
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$1.24
Rate for Payer: SELF PAY	$1.24

Know your out-of-pocket cost for care.

All Charges