Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

INR

Facility

$4.55

Service Code	CPT 85610
Hospital Revenue Code	300
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$2.27
Rate for Payer: SELF PAY	$2.27

INTERDRY

Facility

$143.94

Hospital Revenue Code	270
Min. Negotiated Rate	$71.97
Max. Negotiated Rate	$71.97
Rate for Payer: SELF PAY	$71.97

Interstitial lung disease with CC

Facility

$60,800.00

Service Code	MSDRG 197
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

Interstitial lung disease with MCC

Facility

$86,400.00

Service Code	MSDRG 196
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

Interstitial lung disease without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 198
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

Intracranial hemorrhage or cerebral infarction with CC or tPA in 24 hours

Facility

$51,200.00

Service Code	MSDRG 65
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

Intracranial hemorrhage or cerebral infarction with MCC

Facility

$86,400.00

Service Code	MSDRG 64
Min. Negotiated Rate	$58,430.34
Max. Negotiated Rate	$64,922.60
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$64,922.60
Rate for Payer: American Health Plans Medicare Advantage	$64,922.60
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$64,922.60
Rate for Payer: CIGNA Medicare Advantage	$64,922.60
Rate for Payer: HealthChoice Utah Medicare Advantage	$64,922.60
Rate for Payer: Humana Medicare Advantage	$64,922.60
Rate for Payer: Medicare	$64,922.60
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$64,922.60
Rate for Payer: MOLINA MEDICARE	$64,922.60
Rate for Payer: Pacific Source Medicare Advantage	$64,922.60
Rate for Payer: Select Health Medicare Advantage	$64,922.60
Rate for Payer: SELF PAY	$43,200.00
Rate for Payer: Tricare West Military	$58,430.34

Intracranial hemorrhage or cerebral infarction without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 66
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

Intracranial vascular procedures with principal diagnosis hemorrhage with CC

Facility

$112,000.00

Service Code	MSDRG 21
Min. Negotiated Rate	$62,443.10
Max. Negotiated Rate	$69,381.22
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$69,381.22
Rate for Payer: American Health Plans Medicare Advantage	$69,381.22
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$69,381.22
Rate for Payer: CIGNA Medicare Advantage	$69,381.22
Rate for Payer: HealthChoice Utah Medicare Advantage	$69,381.22
Rate for Payer: Humana Medicare Advantage	$69,381.22
Rate for Payer: Medicare	$69,381.22
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$69,381.22
Rate for Payer: MOLINA MEDICARE	$69,381.22
Rate for Payer: Pacific Source Medicare Advantage	$69,381.22
Rate for Payer: Select Health Medicare Advantage	$69,381.22
Rate for Payer: SELF PAY	$56,000.00
Rate for Payer: Tricare West Military	$62,443.10

Intracranial vascular procedures with principal diagnosis hemorrhage with MCC

Facility

$112,000.00

Service Code	MSDRG 20
Min. Negotiated Rate	$62,443.10
Max. Negotiated Rate	$69,381.22
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$69,381.22
Rate for Payer: American Health Plans Medicare Advantage	$69,381.22
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$69,381.22
Rate for Payer: CIGNA Medicare Advantage	$69,381.22
Rate for Payer: HealthChoice Utah Medicare Advantage	$69,381.22
Rate for Payer: Humana Medicare Advantage	$69,381.22
Rate for Payer: Medicare	$69,381.22
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$69,381.22
Rate for Payer: MOLINA MEDICARE	$69,381.22
Rate for Payer: Pacific Source Medicare Advantage	$69,381.22
Rate for Payer: Select Health Medicare Advantage	$69,381.22
Rate for Payer: SELF PAY	$56,000.00
Rate for Payer: Tricare West Military	$62,443.10

Intracranial vascular procedures with principal diagnosis hemorrhage without CC/MCC

Facility

$112,000.00

Service Code	MSDRG 22
Min. Negotiated Rate	$62,443.10
Max. Negotiated Rate	$69,381.22
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$69,381.22
Rate for Payer: American Health Plans Medicare Advantage	$69,381.22
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$69,381.22
Rate for Payer: CIGNA Medicare Advantage	$69,381.22
Rate for Payer: HealthChoice Utah Medicare Advantage	$69,381.22
Rate for Payer: Humana Medicare Advantage	$69,381.22
Rate for Payer: Medicare	$69,381.22
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$69,381.22
Rate for Payer: MOLINA MEDICARE	$69,381.22
Rate for Payer: Pacific Source Medicare Advantage	$69,381.22
Rate for Payer: Select Health Medicare Advantage	$69,381.22
Rate for Payer: SELF PAY	$56,000.00
Rate for Payer: Tricare West Military	$62,443.10

Intraocular procedures with CC/MCC

Facility

$102,400.00

Service Code	MSDRG 116
Min. Negotiated Rate	$60,834.78
Max. Negotiated Rate	$67,594.20
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$67,594.20
Rate for Payer: American Health Plans Medicare Advantage	$67,594.20
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$67,594.20
Rate for Payer: CIGNA Medicare Advantage	$67,594.20
Rate for Payer: HealthChoice Utah Medicare Advantage	$67,594.20
Rate for Payer: Humana Medicare Advantage	$67,594.20
Rate for Payer: Medicare	$67,594.20
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$67,594.20
Rate for Payer: MOLINA MEDICARE	$67,594.20
Rate for Payer: Pacific Source Medicare Advantage	$67,594.20
Rate for Payer: Select Health Medicare Advantage	$67,594.20
Rate for Payer: SELF PAY	$51,200.00
Rate for Payer: Tricare West Military	$60,834.78

Intraocular procedures without CC/MCC

Facility

$86,400.00

Service Code	MSDRG 117
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

IODINE SWABSTICKS

Facility

$0.12

Hospital Revenue Code	270
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.06
Rate for Payer: SELF PAY	$0.06

IODINE SWABSTICKS WP

Facility

$0.12

Hospital Revenue Code	270
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.06
Rate for Payer: SELF PAY	$0.06

Ischemic stroke, precerebral occlusion or transient ischemia with thrombolytic agent with CC

Facility

$51,200.00

Service Code	MSDRG 62
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

Ischemic stroke, precerebral occlusion or transient ischemia with thrombolytic agent with MCC

Facility

$86,400.00

Service Code	MSDRG 61
Min. Negotiated Rate	$58,430.34
Max. Negotiated Rate	$64,922.60
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$64,922.60
Rate for Payer: American Health Plans Medicare Advantage	$64,922.60
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$64,922.60
Rate for Payer: CIGNA Medicare Advantage	$64,922.60
Rate for Payer: HealthChoice Utah Medicare Advantage	$64,922.60
Rate for Payer: Humana Medicare Advantage	$64,922.60
Rate for Payer: Medicare	$64,922.60
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$64,922.60
Rate for Payer: MOLINA MEDICARE	$64,922.60
Rate for Payer: Pacific Source Medicare Advantage	$64,922.60
Rate for Payer: Select Health Medicare Advantage	$64,922.60
Rate for Payer: SELF PAY	$43,200.00
Rate for Payer: Tricare West Military	$58,430.34

Ischemic stroke, precerebral occlusion or transient ischemia with thrombolytic agent without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 63
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

ISLAND DRESSING 4x10

Facility

$0.60

Hospital Revenue Code	270
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.30
Rate for Payer: SELF PAY	$0.30

ISLAND DRESSING 4X10 WP

Facility

$0.60

Hospital Revenue Code	270
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.30
Rate for Payer: SELF PAY	$0.30

ISO-GUARD ESPIRIT ADULT CIRCUI

Facility

$75.84

Hospital Revenue Code	270
Min. Negotiated Rate	$37.92
Max. Negotiated Rate	$37.92
Rate for Payer: SELF PAY	$37.92

ISOLATION GOWN THUMBLOOP

Facility

$10.90

Hospital Revenue Code	270
Min. Negotiated Rate	$5.45
Max. Negotiated Rate	$5.45
Rate for Payer: SELF PAY	$5.45

ISOLATION GOWN THUMBLOOP WP

Facility

$10.90

Hospital Revenue Code	270
Min. Negotiated Rate	$5.45
Max. Negotiated Rate	$5.45
Rate for Payer: SELF PAY	$5.45

ISOLYSER POWDER (PREMICIDE)

Facility

$2.34

Hospital Revenue Code	270
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.17
Rate for Payer: SELF PAY	$1.17

ISOLYSER POWDER (PREMICIDE) WP

Facility

$2.34

Hospital Revenue Code	270
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.17
Rate for Payer: SELF PAY	$1.17

Know your out-of-pocket cost for care.

All Charges