Western Peaks Specialty Hospital

All Charges

Charge

Type

Price

CONCHA STERILE WATER CANISTER

Facility IP

$5.64

Hospital Revenue Code	270
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$2.82
Rate for Payer: SELF PAY	$2.82

Concomitant aortic and mitral valve�procedures

Facility IP

$86,400.00

Service Code	MSDRG 212
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

Concussion with CC

Facility IP

$67,200.00

Service Code	MSDRG 89
Min. Negotiated Rate	$28,266.26
Max. Negotiated Rate	$31,406.95
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$31,406.95
Rate for Payer: American Health Plans Medicare Advantage	$31,406.95
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$31,406.95
Rate for Payer: CIGNA Medicare Advantage	$31,406.95
Rate for Payer: HealthChoice Utah Medicare Advantage	$31,406.95
Rate for Payer: Humana Medicare Advantage	$31,406.95
Rate for Payer: Medicare	$31,406.95
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$31,406.95
Rate for Payer: MOLINA MEDICARE	$31,406.95
Rate for Payer: Pacific Source Medicare Advantage	$31,406.95
Rate for Payer: Select Health Medicare Advantage	$31,406.95
Rate for Payer: SELF PAY	$33,600.00
Rate for Payer: Tricare West Military	$28,266.26

Concussion with MCC

Facility IP

$76,800.00

Service Code	MSDRG 88
Min. Negotiated Rate	$35,817.33
Max. Negotiated Rate	$39,797.03
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$39,797.03
Rate for Payer: American Health Plans Medicare Advantage	$39,797.03
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$39,797.03
Rate for Payer: CIGNA Medicare Advantage	$39,797.03
Rate for Payer: HealthChoice Utah Medicare Advantage	$39,797.03
Rate for Payer: Humana Medicare Advantage	$39,797.03
Rate for Payer: Medicare	$39,797.03
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$39,797.03
Rate for Payer: MOLINA MEDICARE	$39,797.03
Rate for Payer: Pacific Source Medicare Advantage	$39,797.03
Rate for Payer: Select Health Medicare Advantage	$39,797.03
Rate for Payer: SELF PAY	$38,400.00
Rate for Payer: Tricare West Military	$35,817.33

Concussion without CC/MCC

Facility IP

$60,800.00

Service Code	MSDRG 90
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

CONFORMING STRETCH GAUZE BANDA

Facility IP

$0.28

Hospital Revenue Code	270
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.14
Rate for Payer: SELF PAY	$0.14

Connecting Tubes with Drainage

Facility IP

$57.20

Hospital Revenue Code	270
Min. Negotiated Rate	$28.60
Max. Negotiated Rate	$28.60
Rate for Payer: SELF PAY	$28.60

Connective tissue disorders with CC

Facility IP

$80,000.00

Service Code	MSDRG 546
Min. Negotiated Rate	$31,949.32
Max. Negotiated Rate	$35,499.24
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$35,499.24
Rate for Payer: American Health Plans Medicare Advantage	$35,499.24
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$35,499.24
Rate for Payer: CIGNA Medicare Advantage	$35,499.24
Rate for Payer: HealthChoice Utah Medicare Advantage	$35,499.24
Rate for Payer: Humana Medicare Advantage	$35,499.24
Rate for Payer: Medicare	$35,499.24
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$35,499.24
Rate for Payer: MOLINA MEDICARE	$35,499.24
Rate for Payer: Pacific Source Medicare Advantage	$35,499.24
Rate for Payer: Select Health Medicare Advantage	$35,499.24
Rate for Payer: SELF PAY	$40,000.00
Rate for Payer: Tricare West Military	$31,949.32

Connective tissue disorders with MCC

Facility IP

$86,400.00

Service Code	MSDRG 545
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

Connective tissue disorders without CC/MCC

Facility IP

$64,000.00

Service Code	MSDRG 547
Min. Negotiated Rate	$27,594.78
Max. Negotiated Rate	$30,660.87
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$30,660.87
Rate for Payer: American Health Plans Medicare Advantage	$30,660.87
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$30,660.87
Rate for Payer: CIGNA Medicare Advantage	$30,660.87
Rate for Payer: HealthChoice Utah Medicare Advantage	$30,660.87
Rate for Payer: Humana Medicare Advantage	$30,660.87
Rate for Payer: Medicare	$30,660.87
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$30,660.87
Rate for Payer: MOLINA MEDICARE	$30,660.87
Rate for Payer: Pacific Source Medicare Advantage	$30,660.87
Rate for Payer: Select Health Medicare Advantage	$30,660.87
Rate for Payer: SELF PAY	$32,000.00
Rate for Payer: Tricare West Military	$27,594.78

CONNECTOR 1/4" STRAIGHT

Facility IP

$0.24

Hospital Revenue Code	270
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.12
Rate for Payer: SELF PAY	$0.12

CORGRIP NG / NI FEEDING TUBE

Facility IP

$217.18

Hospital Revenue Code	270
Min. Negotiated Rate	$108.59
Max. Negotiated Rate	$108.59
Rate for Payer: SELF PAY	$108.59

Coronary bypass with cardiac catheterization or open ablation with MCC

Facility IP

$112,000.00

Service Code	MSDRG 233
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

Coronary bypass with cardiac catheterization or open ablation without MCC

Facility IP

$86,400.00

Service Code	MSDRG 234
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

Coronary bypass without cardiac catheterization with MCC

Facility IP

$112,000.00

Service Code	MSDRG 235
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

Coronary bypass without cardiac catheterization without MCC

Facility IP

$86,400.00

Service Code	MSDRG 236
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

Coronary bypass with PTCA with MCC

Facility IP

$112,000.00

Service Code	MSDRG 231
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

Coronary bypass with PTCA without MCC

Facility IP

$86,400.00

Service Code	MSDRG 232
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

Coronary intravascular lithotripsy with intraluminal device with MCC

Facility IP

$86,400.00

Service Code	MSDRG 323
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

Coronary intravascular lithotripsy with intraluminal device without MCC

Facility IP

$86,400.00

Service Code	MSDRG 324
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

Coronary intravascular lithotripsy without intraluminal device

Facility IP

$86,400.00

Service Code	MSDRG 325
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

CORRUGATED TUBING

Facility IP

$0.12

Hospital Revenue Code	270
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.06
Rate for Payer: SELF PAY	$0.06

CORRUGATED TUBING WP

Facility IP

$0.12

Hospital Revenue Code	270
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.06
Rate for Payer: SELF PAY	$0.06

CORTISOL

Facility IP

$39.00

Service Code	CPT 82533
Hospital Revenue Code	300
Min. Negotiated Rate	$19.50
Max. Negotiated Rate	$19.50
Rate for Payer: SELF PAY	$19.50

CORTISOL AM

Facility IP

$39.00

Service Code	CPT 82533
Hospital Revenue Code	300
Min. Negotiated Rate	$19.50
Max. Negotiated Rate	$19.50
Rate for Payer: SELF PAY	$19.50

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