Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

Dental and oral diseases with MCC

Facility

$86,400.00

Service Code	MSDRG 157
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

Dental and oral diseases without CC/MCC

Facility

$70,400.00

Service Code	MSDRG 159
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

DENTAL FLOSS

Facility

$0.70

Hospital Revenue Code	270
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.35
Rate for Payer: SELF PAY	$0.35

DENTAL FLOSS WP

Facility

$0.70

Hospital Revenue Code	270
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.35
Rate for Payer: SELF PAY	$0.35

DENTURE ADHESIVE

Facility

$3.14

Hospital Revenue Code	270
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$1.57
Rate for Payer: SELF PAY	$1.57

DENTURE CUP

Facility

$0.46

Hospital Revenue Code	270
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.23
Rate for Payer: SELF PAY	$0.23

DENTURE CUP WP

Facility

$0.46

Hospital Revenue Code	270
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.23
Rate for Payer: SELF PAY	$0.23

DENTURE TABLET

Facility

$0.06

Hospital Revenue Code	270
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.03
Rate for Payer: SELF PAY	$0.03

DENTURE TABLET WP

Facility

$0.06

Hospital Revenue Code	270
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.03
Rate for Payer: SELF PAY	$0.03

DEODORANT STICK

Facility

$2.06

Hospital Revenue Code	270
Min. Negotiated Rate	$1.03
Max. Negotiated Rate	$1.03
Rate for Payer: SELF PAY	$1.03

DEODORANT STICK WP

Facility

$2.06

Hospital Revenue Code	270
Min. Negotiated Rate	$1.03
Max. Negotiated Rate	$1.03
Rate for Payer: SELF PAY	$1.03

DETANGLER SPRAY WP

Facility

$13.30

Hospital Revenue Code	270
Min. Negotiated Rate	$6.65
Max. Negotiated Rate	$6.65
Rate for Payer: SELF PAY	$6.65

Diabetes with CC

Facility

$67,200.00

Service Code	MSDRG 638
Min. Negotiated Rate	$27,305.29
Max. Negotiated Rate	$30,339.21
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$30,339.21
Rate for Payer: American Health Plans Medicare Advantage	$30,339.21
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$30,339.21
Rate for Payer: CIGNA Medicare Advantage	$30,339.21
Rate for Payer: HealthChoice Utah Medicare Advantage	$30,339.21
Rate for Payer: Humana Medicare Advantage	$30,339.21
Rate for Payer: Medicare	$30,339.21
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$30,339.21
Rate for Payer: MOLINA MEDICARE	$30,339.21
Rate for Payer: Pacific Source Medicare Advantage	$30,339.21
Rate for Payer: Select Health Medicare Advantage	$30,339.21
Rate for Payer: SELF PAY	$33,600.00
Rate for Payer: Tricare West Military	$27,305.29

Diabetes with MCC

Facility

$80,000.00

Service Code	MSDRG 637
Min. Negotiated Rate	$37,542.26
Max. Negotiated Rate	$41,713.62
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$41,713.62
Rate for Payer: American Health Plans Medicare Advantage	$41,713.62
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$41,713.62
Rate for Payer: CIGNA Medicare Advantage	$41,713.62
Rate for Payer: HealthChoice Utah Medicare Advantage	$41,713.62
Rate for Payer: Humana Medicare Advantage	$41,713.62
Rate for Payer: Medicare	$41,713.62
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$41,713.62
Rate for Payer: MOLINA MEDICARE	$41,713.62
Rate for Payer: Pacific Source Medicare Advantage	$41,713.62
Rate for Payer: Select Health Medicare Advantage	$41,713.62
Rate for Payer: SELF PAY	$40,000.00
Rate for Payer: Tricare West Military	$37,542.26

Diabetes without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 639
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

Digestive malignancy with CC

Facility

$51,200.00

Service Code	MSDRG 375
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

Digestive malignancy with MCC

Facility

$70,400.00

Service Code	MSDRG 374
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

Digestive malignancy without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 376
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

DIGOXIN LEVEL

Facility

$15.30

Service Code	CPT 80162
Hospital Revenue Code	300
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$7.65
Rate for Payer: SELF PAY	$7.65

DILANTIN LEVEL

Facility

$15.25

Service Code	CPT 80185
Hospital Revenue Code	300
Min. Negotiated Rate	$7.62
Max. Negotiated Rate	$7.62
Rate for Payer: SELF PAY	$7.62

Disorders of liver except malignancy, cirrhosis or alcoholic hepatitis with CC

Facility

$60,800.00

Service Code	MSDRG 442
Min. Negotiated Rate	$24,374.11
Max. Negotiated Rate	$27,082.35
Rate for Payer: Pacific Source Medicare Advantage	$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: Select Health Medicare Advantage	$27,082.35
Rate for Payer: SELF PAY	$30,400.00
Rate for Payer: Tricare West Military	$24,374.11

Disorders of liver except malignancy, cirrhosis or alcoholic hepatitis with MCC

Facility

$64,000.00

Service Code	MSDRG 441
Min. Negotiated Rate	$31,828.69
Max. Negotiated Rate	$35,365.21
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$35,365.21
Rate for Payer: American Health Plans Medicare Advantage	$35,365.21
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$35,365.21
Rate for Payer: CIGNA Medicare Advantage	$35,365.21
Rate for Payer: HealthChoice Utah Medicare Advantage	$35,365.21
Rate for Payer: Humana Medicare Advantage	$35,365.21
Rate for Payer: Medicare	$35,365.21
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$35,365.21
Rate for Payer: MOLINA MEDICARE	$35,365.21
Rate for Payer: Pacific Source Medicare Advantage	$35,365.21
Rate for Payer: Select Health Medicare Advantage	$35,365.21
Rate for Payer: SELF PAY	$32,000.00
Rate for Payer: Tricare West Military	$31,828.69

Disorders of liver except malignancy, cirrhosis or alcoholic hepatitis without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 443
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

Disorders of pancreas except malignancy with CC

Facility

$70,400.00

Service Code	MSDRG 439
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

Disorders of pancreas except malignancy with MCC

Facility

$83,200.00

Service Code	MSDRG 438
Min. Negotiated Rate	$40,766.94
Max. Negotiated Rate	$45,296.60
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$45,296.60
Rate for Payer: American Health Plans Medicare Advantage	$45,296.60
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$45,296.60
Rate for Payer: CIGNA Medicare Advantage	$45,296.60
Rate for Payer: HealthChoice Utah Medicare Advantage	$45,296.60
Rate for Payer: Humana Medicare Advantage	$45,296.60
Rate for Payer: Medicare	$45,296.60
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$45,296.60
Rate for Payer: MOLINA MEDICARE	$45,296.60
Rate for Payer: Pacific Source Medicare Advantage	$45,296.60
Rate for Payer: Select Health Medicare Advantage	$45,296.60
Rate for Payer: SELF PAY	$41,600.00
Rate for Payer: Tricare West Military	$40,766.94

Know your out-of-pocket cost for care.

All Charges