Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

Acute and subacute endocarditis with MCC

Facility

$83,200.00

Service Code	MSDRG 288
Min. Negotiated Rate	$41,764.10
Max. Negotiated Rate	$46,404.56
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$46,404.56
Rate for Payer: American Health Plans Medicare Advantage	$46,404.56
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$46,404.56
Rate for Payer: CIGNA Medicare Advantage	$46,404.56
Rate for Payer: HealthChoice Utah Medicare Advantage	$46,404.56
Rate for Payer: Humana Medicare Advantage	$46,404.56
Rate for Payer: Medicare	$46,404.56
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$46,404.56
Rate for Payer: MOLINA MEDICARE	$46,404.56
Rate for Payer: Pacific Source Medicare Advantage	$46,404.56
Rate for Payer: Select Health Medicare Advantage	$46,404.56
Rate for Payer: SELF PAY	$41,600.00
Rate for Payer: Tricare West Military	$41,764.10

Acute and subacute endocarditis without CC/MCC*

Facility

$70,400.00

Service Code	MSDRG 290
Min. Negotiated Rate	$25,616.55
Max. Negotiated Rate	$28,462.83
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$28,462.83
Rate for Payer: American Health Plans Medicare Advantage	$28,462.83
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$28,462.83
Rate for Payer: CIGNA Medicare Advantage	$28,462.83
Rate for Payer: HealthChoice Utah Medicare Advantage	$28,462.83
Rate for Payer: Humana Medicare Advantage	$28,462.83
Rate for Payer: Medicare	$28,462.83
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$28,462.83
Rate for Payer: MOLINA MEDICARE	$28,462.83
Rate for Payer: Pacific Source Medicare Advantage	$28,462.83
Rate for Payer: Select Health Medicare Advantage	$28,462.83
Rate for Payer: SELF PAY	$35,200.00
Rate for Payer: Tricare West Military	$25,616.55

Acute leukemia without major O.R. procedures with CC

Facility

$70,400.00

Service Code	MSDRG 835
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

Acute leukemia without major O.R. procedures with MCC

Facility

$70,400.00

Service Code	MSDRG 834
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

Acute leukemia without major O.R. procedures without CC/MCC

Facility

$70,400.00

Service Code	MSDRG 836
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

Acute major eye infections with CC/MCC

Facility

$51,200.00

Service Code	MSDRG 121
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

Acute major eye infections without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 122
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

Acute myocardial infarction, discharged alive with CC

Facility

$60,800.00

Service Code	MSDRG 281
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

Acute myocardial infarction, discharged alive with MCC

Facility

$70,400.00

Service Code	MSDRG 280
Min. Negotiated Rate	$33,525.47
Max. Negotiated Rate	$37,250.52
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$37,250.52
Rate for Payer: American Health Plans Medicare Advantage	$37,250.52
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$37,250.52
Rate for Payer: CIGNA Medicare Advantage	$37,250.52
Rate for Payer: HealthChoice Utah Medicare Advantage	$37,250.52
Rate for Payer: Humana Medicare Advantage	$37,250.52
Rate for Payer: Medicare	$37,250.52
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$37,250.52
Rate for Payer: MOLINA MEDICARE	$37,250.52
Rate for Payer: Pacific Source Medicare Advantage	$37,250.52
Rate for Payer: Select Health Medicare Advantage	$37,250.52
Rate for Payer: SELF PAY	$35,200.00
Rate for Payer: Tricare West Military	$33,525.47

Acute myocardial infarction, discharged alive without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 282
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

Acute myocardial infarction, expired with CC

Facility

$51,200.00

Service Code	MSDRG 284
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

Acute myocardial infarction, expired with MCC

Facility

$70,400.00

Service Code	MSDRG 283
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

Acute myocardial infarction, expired without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 285
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

ADAPTER 2 STEP 15mm x 22mm

Facility

$1.36

Hospital Revenue Code	270
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.68
Rate for Payer: SELF PAY	$0.68

ADAPTER 2 STEP 15mm x 22mm WP

Facility

$1.36

Hospital Revenue Code	270
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.68
Rate for Payer: SELF PAY	$0.68

ADAPTER MULTI

Facility

$0.62

Hospital Revenue Code	270
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.31
Rate for Payer: SELF PAY	$0.31

ADAPTER MULTI WP

Facility

$0.62

Hospital Revenue Code	270
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.31
Rate for Payer: SELF PAY	$0.31

ADAPTER SET, NOMOLINE AIRWAY A

Facility

$33.90

Hospital Revenue Code	270
Min. Negotiated Rate	$16.95
Max. Negotiated Rate	$16.95
Rate for Payer: SELF PAY	$16.95

ADAPTER SWIVEL

Facility

$3.64

Hospital Revenue Code	270
Min. Negotiated Rate	$1.82
Max. Negotiated Rate	$1.82
Rate for Payer: SELF PAY	$1.82

ADAPTER SWIVEL WP

Facility

$3.64

Hospital Revenue Code	270
Min. Negotiated Rate	$1.82
Max. Negotiated Rate	$1.82
Rate for Payer: SELF PAY	$1.82

ADAPTER UNIVERSAL

Facility

$0.42

Hospital Revenue Code	270
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.21
Rate for Payer: SELF PAY	$0.21

ADAPTER UNIVERSAL WP

Facility

$0.42

Hospital Revenue Code	270
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.21
Rate for Payer: SELF PAY	$0.21

ADAPTER VALVED T

Facility

$6.44

Hospital Revenue Code	270
Min. Negotiated Rate	$3.22
Max. Negotiated Rate	$3.22
Rate for Payer: SELF PAY	$3.22

ADAPTER VALVED T WP

Facility

$6.44

Hospital Revenue Code	270
Min. Negotiated Rate	$3.22
Max. Negotiated Rate	$3.22
Rate for Payer: SELF PAY	$3.22

ADAPTIC (EMULSION) DRESSING 3"

Facility

$2.94

Hospital Revenue Code	270
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$1.47
Rate for Payer: SELF PAY	$1.47
Rate for Payer: SELF PAY	$1.06

Know your out-of-pocket cost for care.

All Charges