Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

Full thickness burn with skin graft or inhalation injury with CC/MCC

Facility

$70,400.00

Service Code	MSDRG 928
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

Full thickness burn with skin graft or inhalation injury without CC/MCC

Facility

$70,400.00

Service Code	MSDRG 929
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

FULL VEST ADULT LARGE

Facility

$135.20

Hospital Revenue Code	270
Min. Negotiated Rate	$67.60
Max. Negotiated Rate	$67.60
Rate for Payer: SELF PAY	$67.60

FULL VEST ADULT MEDIUM

Facility

$135.20

Hospital Revenue Code	270
Min. Negotiated Rate	$67.60
Max. Negotiated Rate	$67.60
Rate for Payer: SELF PAY	$67.60

FULL VEST ADULT SMALL

Facility

$135.20

Hospital Revenue Code	270
Min. Negotiated Rate	$67.60
Max. Negotiated Rate	$67.60
Rate for Payer: SELF PAY	$67.60

FULL VEST ADULT XS SLIM

Facility

$135.20

Hospital Revenue Code	270
Min. Negotiated Rate	$67.60
Max. Negotiated Rate	$67.60
Rate for Payer: SELF PAY	$67.60

FULL VEST CHILD LARGE

Facility

$135.20

Hospital Revenue Code	270
Min. Negotiated Rate	$67.60
Max. Negotiated Rate	$67.60
Rate for Payer: SELF PAY	$67.60

FUNGUS CULTURE WOUND

Facility

$99.00

Service Code	CPT 87101
Hospital Revenue Code	300
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$49.50
Rate for Payer: SELF PAY	$49.50

FUNGUS SUSCEPT

Facility

$58.28

Service Code	CPT 87102
Hospital Revenue Code	300
Min. Negotiated Rate	$29.14
Max. Negotiated Rate	$29.14
Rate for Payer: SELF PAY	$29.14

Gait Belt

Facility

$6.00

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

Gait Belt Long

Facility

$9.70

Hospital Revenue Code	270
Min. Negotiated Rate	$4.85
Max. Negotiated Rate	$4.85
Rate for Payer: SELF PAY	$4.85

Gait Training 1 unit

Facility

$41.00

Service Code	CPT 97116
Hospital Revenue Code	420
Min. Negotiated Rate	$20.50
Max. Negotiated Rate	$20.50
Rate for Payer: SELF PAY	$20.50

GAMMA GLUTAMYL TRANSPEPTIDASE

Facility

$21.00

Service Code	CPT 82977
Hospital Revenue Code	300
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$10.50
Rate for Payer: SELF PAY	$10.50

Gas Manifold Filter

Facility

$6.78

Hospital Revenue Code	270
Min. Negotiated Rate	$3.39
Max. Negotiated Rate	$3.39
Rate for Payer: SELF PAY	$3.39

GASTROCCULT

Facility

$5.10

Hospital Revenue Code	270
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.55
Rate for Payer: SELF PAY	$2.55

GASTROCCULT WP

Facility

$5.10

Hospital Revenue Code	270
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.55
Rate for Payer: SELF PAY	$2.55

GASTROCULT SLIDES

Facility

$2.56

Hospital Revenue Code	270
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.28
Rate for Payer: SELF PAY	$1.28

Gastrointestinal hemorrhage with CC

Facility

$51,200.00

Service Code	MSDRG 378
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

Gastrointestinal hemorrhage with MCC

Facility

$70,400.00

Service Code	MSDRG 377
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

Gastrointestinal hemorrhage without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 379
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

Gastrointestinal obstruction with CC

Facility

$70,400.00

Service Code	MSDRG 389
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

Gastrointestinal obstruction with MCC

Facility

$76,800.00

Service Code	MSDRG 388
Min. Negotiated Rate	$40,887.57
Max. Negotiated Rate	$45,430.63
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$45,430.63
Rate for Payer: American Health Plans Medicare Advantage	$45,430.63
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$45,430.63
Rate for Payer: CIGNA Medicare Advantage	$45,430.63
Rate for Payer: HealthChoice Utah Medicare Advantage	$45,430.63
Rate for Payer: Humana Medicare Advantage	$45,430.63
Rate for Payer: Medicare	$45,430.63
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$45,430.63
Rate for Payer: MOLINA MEDICARE	$45,430.63
Rate for Payer: Pacific Source Medicare Advantage	$45,430.63
Rate for Payer: Select Health Medicare Advantage	$45,430.63
Rate for Payer: SELF PAY	$38,400.00
Rate for Payer: Tricare West Military	$40,887.57

Gastrointestinal obstruction without CC/MCC

Facility

$70,400.00

Service Code	MSDRG 390
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

Gastrostomy Tube with Y Ports

Facility

$59.16

Hospital Revenue Code	270
Min. Negotiated Rate	$29.58
Max. Negotiated Rate	$29.58
Rate for Payer: SELF PAY	$29.58

GAUZE 2X2 8PLY

Facility

$0.04

Hospital Revenue Code	270
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: SELF PAY	$0.02

Know your out-of-pocket cost for care.

All Charges