Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

Inflammation of the male reproductive system with MCC

Facility

$76,800.00

Service Code	MSDRG 727
Min. Negotiated Rate	$36,275.71
Max. Negotiated Rate	$40,306.34
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$40,306.34
Rate for Payer: American Health Plans Medicare Advantage	$40,306.34
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$40,306.34
Rate for Payer: CIGNA Medicare Advantage	$40,306.34
Rate for Payer: HealthChoice Utah Medicare Advantage	$40,306.34
Rate for Payer: Humana Medicare Advantage	$40,306.34
Rate for Payer: Medicare	$40,306.34
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$40,306.34
Rate for Payer: MOLINA MEDICARE	$40,306.34
Rate for Payer: Pacific Source Medicare Advantage	$40,306.34
Rate for Payer: Select Health Medicare Advantage	$40,306.34
Rate for Payer: SELF PAY	$38,400.00
Rate for Payer: Tricare West Military	$36,275.71

Inflammation of the male reproductive system without MCC

Facility

$60,800.00

Service Code	MSDRG 728
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

Inflammatory bowel disease with CC*

Facility

$60,800.00

Service Code	MSDRG 386
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

Inflammatory bowel disease with MCC

Facility

$60,800.00

Service Code	MSDRG 385
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

Inflammatory bowel disease without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 387
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

INFLUENZA A B ANTIGEN

Facility

$40.00

Service Code	CPT 87502
Hospital Revenue Code	300
Min. Negotiated Rate	$20.00
Max. Negotiated Rate	$20.00
Rate for Payer: SELF PAY	$20.00

INFO Wound VAC

Facility

$130.90

Hospital Revenue Code	290
Min. Negotiated Rate	$65.45
Max. Negotiated Rate	$65.45
Rate for Payer: SELF PAY	$65.45

Inguinal and femoral hernia procedures with CC

Facility

$64,000.00

Service Code	MSDRG 351
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

Inguinal and femoral hernia procedures with MCC

Facility

$76,800.00

Service Code	MSDRG 350
Min. Negotiated Rate	$38,828.92
Max. Negotiated Rate	$43,143.24
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$43,143.24
Rate for Payer: American Health Plans Medicare Advantage	$43,143.24
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$43,143.24
Rate for Payer: CIGNA Medicare Advantage	$43,143.24
Rate for Payer: HealthChoice Utah Medicare Advantage	$43,143.24
Rate for Payer: Humana Medicare Advantage	$43,143.24
Rate for Payer: Medicare	$43,143.24
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$43,143.24
Rate for Payer: MOLINA MEDICARE	$43,143.24
Rate for Payer: Pacific Source Medicare Advantage	$43,143.24
Rate for Payer: Select Health Medicare Advantage	$43,143.24
Rate for Payer: SELF PAY	$38,400.00
Rate for Payer: Tricare West Military	$38,828.92

Inguinal and femoral hernia procedures without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 352
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

INNER CANNULA 10 DIC

Facility

$7.00

Hospital Revenue Code	270
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$3.50
Rate for Payer: SELF PAY	$3.50

INNER CANNULA 4 DIC

Facility

$6.52

Hospital Revenue Code	270
Min. Negotiated Rate	$3.26
Max. Negotiated Rate	$3.26
Rate for Payer: SELF PAY	$3.26

INNER CANNULA 4 DIC WP

Facility

$6.52

Hospital Revenue Code	270
Min. Negotiated Rate	$3.26
Max. Negotiated Rate	$3.26
Rate for Payer: SELF PAY	$3.26

INNER CANNULA 5.0 XLT

Facility

$11.88

Hospital Revenue Code	270
Min. Negotiated Rate	$5.94
Max. Negotiated Rate	$5.94
Rate for Payer: SELF PAY	$5.94

INNER CANNULA 5.0 XLT WP

Facility

$11.88

Hospital Revenue Code	270
Min. Negotiated Rate	$5.94
Max. Negotiated Rate	$5.94
Rate for Payer: SELF PAY	$5.94

INNER CANNULA 6.0 XLT

Facility

$11.48

Hospital Revenue Code	270
Min. Negotiated Rate	$5.74
Max. Negotiated Rate	$5.74
Rate for Payer: SELF PAY	$5.74

INNER CANNULA 6.0 XLT WP

Facility

$11.48

Hospital Revenue Code	270
Min. Negotiated Rate	$5.74
Max. Negotiated Rate	$5.74
Rate for Payer: SELF PAY	$5.74

INNER CANNULA 6 DIC

Facility

$6.52

Hospital Revenue Code	270
Min. Negotiated Rate	$3.26
Max. Negotiated Rate	$3.26
Rate for Payer: SELF PAY	$3.26

INNER CANNULA 6 DIC WP

Facility

$6.52

Hospital Revenue Code	270
Min. Negotiated Rate	$3.26
Max. Negotiated Rate	$3.26
Rate for Payer: SELF PAY	$3.26

INNER CANNULA 7.0 XLT

Facility

$11.34

Hospital Revenue Code	270
Min. Negotiated Rate	$5.67
Max. Negotiated Rate	$5.67
Rate for Payer: SELF PAY	$5.67

INNER CANNULA 7.0 XLT WP

Facility

$11.34

Hospital Revenue Code	270
Min. Negotiated Rate	$5.67
Max. Negotiated Rate	$5.67
Rate for Payer: SELF PAY	$5.67

INNER CANNULA 8.0 XLT

Facility

$12.30

Hospital Revenue Code	270
Min. Negotiated Rate	$6.15
Max. Negotiated Rate	$6.15
Rate for Payer: SELF PAY	$6.15

INNER CANNULA 8.0 XLT WP

Facility

$12.30

Hospital Revenue Code	270
Min. Negotiated Rate	$6.15
Max. Negotiated Rate	$6.15
Rate for Payer: SELF PAY	$6.15

INNER CANNULA 8 DIC

Facility

$6.52

Hospital Revenue Code	270
Min. Negotiated Rate	$3.26
Max. Negotiated Rate	$3.26
Rate for Payer: SELF PAY	$3.26

INNER CANNULA 8 DIC WP

Facility

$6.52

Hospital Revenue Code	270
Min. Negotiated Rate	$3.26
Max. Negotiated Rate	$3.26
Rate for Payer: SELF PAY	$3.26

Know your out-of-pocket cost for care.

All Charges