Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

CREATINE KINASE MB

Facility

$53.00

Service Code	CPT 82553
Hospital Revenue Code	300
Min. Negotiated Rate	$26.50
Max. Negotiated Rate	$26.50
Rate for Payer: SELF PAY	$26.50

CREATININE

Facility

$3.16

Service Code	CPT 82565
Hospital Revenue Code	300
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$1.58
Rate for Payer: SELF PAY	$1.58

CRP (C-Reactive Protein)

Facility

$6.00

Service Code	CPT 86140
Hospital Revenue Code	300
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$3.00
Rate for Payer: SELF PAY	$3.00

C + S (85302)

Facility

$27.25

Service Code	CPT 85302
Hospital Revenue Code	300
Min. Negotiated Rate	$13.62
Max. Negotiated Rate	$13.62
Rate for Payer: SELF PAY	$13.62

C + S (85305)

Facility

$27.25

Service Code	CPT 85305
Hospital Revenue Code	300
Min. Negotiated Rate	$13.62
Max. Negotiated Rate	$13.62
Rate for Payer: SELF PAY	$13.62

CULTURE (ANAER)

Facility

$19.30

Service Code	CPT 87070
Hospital Revenue Code	300
Min. Negotiated Rate	$9.65
Max. Negotiated Rate	$9.65
Rate for Payer: SELF PAY	$9.65

CULTURE (BACT)

Facility

$19.30

Service Code	CPT 87070
Hospital Revenue Code	300
Min. Negotiated Rate	$9.65
Max. Negotiated Rate	$9.65
Rate for Payer: SELF PAY	$9.65

CUSTOM BIVONA TRACH 3.5 NSF973

Facility

$740.00

Hospital Revenue Code	270
Min. Negotiated Rate	$370.00
Max. Negotiated Rate	$370.00
Rate for Payer: SELF PAY	$370.00

CUSTOM BIVONA TRACH 3.5 SE968N

Facility

$740.00

Hospital Revenue Code	270
Min. Negotiated Rate	$370.00
Max. Negotiated Rate	$370.00
Rate for Payer: SELF PAY	$370.00

CUSTOM BIVONA TRACH 3.5 SE971

Facility

$740.00

Hospital Revenue Code	270
Min. Negotiated Rate	$370.00
Max. Negotiated Rate	$370.00
Rate for Payer: SELF PAY	$370.00

CUSTOM BIVONA TRACH 3.5 SF967N

Facility

$740.00

Hospital Revenue Code	270
Min. Negotiated Rate	$370.00
Max. Negotiated Rate	$370.00
Rate for Payer: SELF PAY	$370.00

CUSTOM BIVONA TRACH 3.5 SF970N

Facility

$740.00

Hospital Revenue Code	270
Min. Negotiated Rate	$370.00
Max. Negotiated Rate	$370.00
Rate for Payer: SELF PAY	$370.00

CUSTOM BIVONA TRACH 4.0 FSF966

Facility

$740.00

Hospital Revenue Code	270
Min. Negotiated Rate	$370.00
Max. Negotiated Rate	$370.00
Rate for Payer: SELF PAY	$370.00

CUTIMED SORBACT WOUND DRESSING

Facility

$14.84

Hospital Revenue Code	270
Min. Negotiated Rate	$7.42
Max. Negotiated Rate	$7.42
Rate for Payer: SELF PAY	$7.42

CYSTATIN C GFR

Facility

$64.04

Service Code	CPT 82610
Hospital Revenue Code	300
Min. Negotiated Rate	$32.02
Max. Negotiated Rate	$32.02
Rate for Payer: SELF PAY	$32.02

D&C, conization, laparoscopy and tubal interruption with CC/MCC

Facility

$70,400.00

Service Code	MSDRG 744
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

D&C, conization, laparoscopy and tubal interruption without CC/MCC

Facility

$70,400.00

Service Code	MSDRG 745
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

D DIMER QUANTITATIVE

Facility

$10.18

Service Code	CPT 85379
Hospital Revenue Code	300
Min. Negotiated Rate	$5.09
Max. Negotiated Rate	$5.09
Rate for Payer: SELF PAY	$5.09

DEAD AIR SPACE

Facility

$5.36

Hospital Revenue Code	270
Min. Negotiated Rate	$2.68
Max. Negotiated Rate	$2.68
Rate for Payer: SELF PAY	$2.68

DEAD AIR SPACE WP

Facility

$5.36

Hospital Revenue Code	270
Min. Negotiated Rate	$2.68
Max. Negotiated Rate	$2.68
Rate for Payer: SELF PAY	$2.68

Deep vein thrombophlebitis with CC/MCC

Facility

$70,400.00

Service Code	MSDRG 294
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

Deep vein thrombophlebitis without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 295
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

Degenerative nervous system disorders with MCC

Facility

$76,800.00

Service Code	MSDRG 56
Min. Negotiated Rate	$32,270.98
Max. Negotiated Rate	$35,856.64
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$35,856.64
Rate for Payer: American Health Plans Medicare Advantage	$35,856.64
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$35,856.64
Rate for Payer: CIGNA Medicare Advantage	$35,856.64
Rate for Payer: HealthChoice Utah Medicare Advantage	$35,856.64
Rate for Payer: Humana Medicare Advantage	$35,856.64
Rate for Payer: Medicare	$35,856.64
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$35,856.64
Rate for Payer: MOLINA MEDICARE	$35,856.64
Rate for Payer: Pacific Source Medicare Advantage	$35,856.64
Rate for Payer: Select Health Medicare Advantage	$35,856.64
Rate for Payer: SELF PAY	$38,400.00
Rate for Payer: Tricare West Military	$32,270.98

Degenerative nervous system disorders without MCC

Facility

$76,800.00

Service Code	MSDRG 57
Min. Negotiated Rate	$27,156.52
Max. Negotiated Rate	$30,173.91
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$30,173.91
Rate for Payer: American Health Plans Medicare Advantage	$30,173.91
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$30,173.91
Rate for Payer: CIGNA Medicare Advantage	$30,173.91
Rate for Payer: HealthChoice Utah Medicare Advantage	$30,173.91
Rate for Payer: Humana Medicare Advantage	$30,173.91
Rate for Payer: Medicare	$30,173.91
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$30,173.91
Rate for Payer: MOLINA MEDICARE	$30,173.91
Rate for Payer: Pacific Source Medicare Advantage	$30,173.91
Rate for Payer: Select Health Medicare Advantage	$30,173.91
Rate for Payer: SELF PAY	$38,400.00
Rate for Payer: Tricare West Military	$27,156.52

Dental and oral diseases with CC

Facility

$70,400.00

Service Code	MSDRG 158
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

Know your out-of-pocket cost for care.

All Charges