Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

Disorders of pancreas except malignancy without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 440
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

Disorders of the biliary tract with CC*

Facility

$67,200.00

Service Code	MSDRG 445
Min. Negotiated Rate	$29,078.46
Max. Negotiated Rate	$32,309.40
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$32,309.40
Rate for Payer: American Health Plans Medicare Advantage	$32,309.40
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$32,309.40
Rate for Payer: CIGNA Medicare Advantage	$32,309.40
Rate for Payer: HealthChoice Utah Medicare Advantage	$32,309.40
Rate for Payer: Humana Medicare Advantage	$32,309.40
Rate for Payer: Medicare	$32,309.40
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$32,309.40
Rate for Payer: MOLINA MEDICARE	$32,309.40
Rate for Payer: Pacific Source Medicare Advantage	$32,309.40
Rate for Payer: Select Health Medicare Advantage	$32,309.40
Rate for Payer: SELF PAY	$33,600.00
Rate for Payer: Tricare West Military	$29,078.46

Disorders of the biliary tract with MCC*

Facility

$67,200.00

Service Code	MSDRG 444
Min. Negotiated Rate	$34,160.76
Max. Negotiated Rate	$37,956.40
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$37,956.40
Rate for Payer: American Health Plans Medicare Advantage	$37,956.40
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$37,956.40
Rate for Payer: CIGNA Medicare Advantage	$37,956.40
Rate for Payer: HealthChoice Utah Medicare Advantage	$37,956.40
Rate for Payer: Humana Medicare Advantage	$37,956.40
Rate for Payer: Medicare	$37,956.40
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$37,956.40
Rate for Payer: MOLINA MEDICARE	$37,956.40
Rate for Payer: Pacific Source Medicare Advantage	$37,956.40
Rate for Payer: Select Health Medicare Advantage	$37,956.40
Rate for Payer: SELF PAY	$33,600.00
Rate for Payer: Tricare West Military	$34,160.76

Disorders of the biliary tract without CC/MCC

Facility

$64,000.00

Service Code	MSDRG 446
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

DISPOSABLE ADULT BLOOD PRESSUR

Facility

$6.00

Hospital Revenue Code	270
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$3.00
Rate for Payer: SELF PAY	$3.00

DISPOSABLE BP CUFF ADULT LONG

Facility

$5.08

Hospital Revenue Code	270
Min. Negotiated Rate	$2.54
Max. Negotiated Rate	$2.54
Rate for Payer: SELF PAY	$2.54

DISPOSABLE PED HEATED CIRCUIT

Facility

$75.20

Hospital Revenue Code	270
Min. Negotiated Rate	$37.60
Max. Negotiated Rate	$37.60
Rate for Payer: SELF PAY	$37.60

Disposable ring electrodes

Facility

$1.08

Hospital Revenue Code	270
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.54
Rate for Payer: SELF PAY	$0.54

Disposable Sterile Scalpels

Facility

$3.02

Hospital Revenue Code	270
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$1.51
Rate for Payer: SELF PAY	$1.51

DISPOSABLE STETHOSCOPE

Facility

$6.00

Hospital Revenue Code	270
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$3.00
Rate for Payer: SELF PAY	$3.00

DISPOSABLE VEST

Facility

$200.00

Hospital Revenue Code	270
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$100.00
Rate for Payer: SELF PAY	$100.00

DISP PASSIVE CIRCUIT TRILOGY

Facility

$33.22

Hospital Revenue Code	270
Min. Negotiated Rate	$16.61
Max. Negotiated Rate	$16.61
Rate for Payer: SELF PAY	$16.61

DISP PASSIVE CIRCUIT TRILOGY W

Facility

$33.22

Hospital Revenue Code	270
Min. Negotiated Rate	$16.61
Max. Negotiated Rate	$16.61
Rate for Payer: SELF PAY	$16.61

Dolphin Mattress

Facility

$133.00

Hospital Revenue Code	290
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$66.50
Rate for Payer: SELF PAY	$66.50

Double Lumen PICC Insertion

Facility

$1,020.00

Hospital Revenue Code	320
Min. Negotiated Rate	$510.00
Max. Negotiated Rate	$510.00
Rate for Payer: SELF PAY	$510.00

Double Midline Insertion

Facility

$800.00

Hospital Revenue Code	320
Min. Negotiated Rate	$400.00
Max. Negotiated Rate	$400.00
Rate for Payer: SELF PAY	$400.00

DRAIN BAG

Facility

$12.20

Hospital Revenue Code	270
Min. Negotiated Rate	$6.10
Max. Negotiated Rate	$6.10
Rate for Payer: SELF PAY	$6.10

DRAIN BAG WP

Facility

$12.20

Hospital Revenue Code	270
Min. Negotiated Rate	$6.10
Max. Negotiated Rate	$6.10
Rate for Payer: SELF PAY	$6.10

DRAIN BAG W/WYE

Facility

$1.74

Hospital Revenue Code	270
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$0.87
Rate for Payer: SELF PAY	$0.87

DRAIN BAG W/WYE WP

Facility

$1.90

Hospital Revenue Code	270
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$0.95
Rate for Payer: SELF PAY	$0.95

DREAMWEAR SILICONE PILLOWS MAS

Facility

$197.32

Hospital Revenue Code	270
Min. Negotiated Rate	$98.66
Max. Negotiated Rate	$98.66
Rate for Payer: SELF PAY	$98.66

DRIFLO PADS (AIR PERMEABLE PAD

Facility

$6.14

Hospital Revenue Code	270
Min. Negotiated Rate	$3.07
Max. Negotiated Rate	$3.07
Rate for Payer: SELF PAY	$3.07
Rate for Payer: SELF PAY	$0.38

DRUG SCREEN

Facility

$42.00

Service Code	CPT 80306
Hospital Revenue Code	300
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$21.00
Rate for Payer: SELF PAY	$21.00

Dysequilibrium

Facility

$60,800.00

Service Code	MSDRG 149
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

EAKIN PASTE CONVATEC COHESIVE

Facility

$17.56

Hospital Revenue Code	270
Min. Negotiated Rate	$8.78
Max. Negotiated Rate	$8.78
Rate for Payer: SELF PAY	$8.78

Know your out-of-pocket cost for care.

All Charges