Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

ADHESIVE RELEASER SPRAY

Facility

$80.80

Hospital Revenue Code	270
Min. Negotiated Rate	$40.40
Max. Negotiated Rate	$40.40
Rate for Payer: SELF PAY	$40.40

ADHESIVE RELEASER SPRAY WP

Facility

$80.80

Hospital Revenue Code	270
Min. Negotiated Rate	$40.40
Max. Negotiated Rate	$40.40
Rate for Payer: SELF PAY	$40.40

ADHESIVE TAPE REMOVER

Facility

$0.16

Hospital Revenue Code	270
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.08
Rate for Payer: SELF PAY	$0.08

ADHESIVE TAPE REMOVER WP

Facility

$0.16

Hospital Revenue Code	270
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.08
Rate for Payer: SELF PAY	$0.08

Adrenal and pituitary procedures with CC/MCC

Facility

$60,800.00

Service Code	MSDRG 614
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

Adrenal and pituitary procedures without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 615
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

ADRENOCORTICOTROPIC H

Facility

$49.00

Service Code	CPT 82024
Hospital Revenue Code	300
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$24.50
Rate for Payer: SELF PAY	$24.50

ADRENOCORTICOTROPIC HORMONE

Facility

$49.00

Service Code	CPT 82024
Hospital Revenue Code	300
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$24.50
Rate for Payer: SELF PAY	$24.50

ADULT HEATED CIRCUIT TRILOGY

Facility

$162.34

Hospital Revenue Code	270
Min. Negotiated Rate	$81.17
Max. Negotiated Rate	$81.17
Rate for Payer: SELF PAY	$81.17

ADULT HEATED CIRCUIT TRIL WP

Facility

$162.34

Hospital Revenue Code	270
Min. Negotiated Rate	$81.17
Max. Negotiated Rate	$81.17
Rate for Payer: SELF PAY	$81.17

ADULT ISO-GUARD DRAIN

Facility

$29.66

Hospital Revenue Code	270
Min. Negotiated Rate	$14.83
Max. Negotiated Rate	$14.83
Rate for Payer: SELF PAY	$14.83

ADULT ISO-GUARD DRAIN WP

Facility

$29.66

Hospital Revenue Code	270
Min. Negotiated Rate	$14.83
Max. Negotiated Rate	$14.83
Rate for Payer: SELF PAY	$14.83

Adult O2/ETCO2 Divided Cannula

Facility

$29.98

Hospital Revenue Code	270
Min. Negotiated Rate	$14.99
Max. Negotiated Rate	$14.99
Rate for Payer: SELF PAY	$14.99

ADULT TRACH 6.0 UNCUFFED

Facility

$144.78

Hospital Revenue Code	270
Min. Negotiated Rate	$72.39
Max. Negotiated Rate	$72.39
Rate for Payer: SELF PAY	$72.39

AEROBIC ID

Facility

$16.00

Service Code	CPT 87077
Hospital Revenue Code	300
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$8.00
Rate for Payer: SELF PAY	$8.00

AEROBIC SENSITIVITY

Facility

$16.00

Service Code	CPT 87077
Hospital Revenue Code	300
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$8.00
Rate for Payer: SELF PAY	$8.00

AERO CHAMBER "ORAL" PLUS

Facility

$22.06

Hospital Revenue Code	270
Min. Negotiated Rate	$11.03
Max. Negotiated Rate	$11.03
Rate for Payer: SELF PAY	$11.03

AERO CHAMBER "ORAL" PLUS WP

Facility

$22.06

Hospital Revenue Code	270
Min. Negotiated Rate	$11.03
Max. Negotiated Rate	$11.03
Rate for Payer: SELF PAY	$11.03

AEROGEN SOLO ADULT T-PIECE

Facility

$6.22

Hospital Revenue Code	270
Min. Negotiated Rate	$3.11
Max. Negotiated Rate	$3.11
Rate for Payer: SELF PAY	$3.11

AEROGEN SOLO KIT

Facility

$210.24

Hospital Revenue Code	270
Min. Negotiated Rate	$105.12
Max. Negotiated Rate	$105.12
Rate for Payer: SELF PAY	$105.12

Aftercare, musculoskeletal system and connective tissue with CC

Facility

$73,600.00

Service Code	MSDRG 560
Min. Negotiated Rate	$28,226.05
Max. Negotiated Rate	$31,362.28
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$31,362.28
Rate for Payer: American Health Plans Medicare Advantage	$31,362.28
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$31,362.28
Rate for Payer: CIGNA Medicare Advantage	$31,362.28
Rate for Payer: HealthChoice Utah Medicare Advantage	$31,362.28
Rate for Payer: Humana Medicare Advantage	$31,362.28
Rate for Payer: Medicare	$31,362.28
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$31,362.28
Rate for Payer: MOLINA MEDICARE	$31,362.28
Rate for Payer: Pacific Source Medicare Advantage	$31,362.28
Rate for Payer: Select Health Medicare Advantage	$31,362.28
Rate for Payer: SELF PAY	$36,800.00
Rate for Payer: Tricare West Military	$28,226.05

Aftercare, musculoskeletal system and connective tissue with MCC

Facility

$80,000.00

Service Code	MSDRG 559
Min. Negotiated Rate	$36,203.33
Max. Negotiated Rate	$40,225.92
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$40,225.92
Rate for Payer: American Health Plans Medicare Advantage	$40,225.92
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$40,225.92
Rate for Payer: CIGNA Medicare Advantage	$40,225.92
Rate for Payer: HealthChoice Utah Medicare Advantage	$40,225.92
Rate for Payer: Humana Medicare Advantage	$40,225.92
Rate for Payer: Medicare	$40,225.92
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$40,225.92
Rate for Payer: MOLINA MEDICARE	$40,225.92
Rate for Payer: Pacific Source Medicare Advantage	$40,225.92
Rate for Payer: Select Health Medicare Advantage	$40,225.92
Rate for Payer: SELF PAY	$40,000.00
Rate for Payer: Tricare West Military	$36,203.33

Aftercare, musculoskeletal system and connective tissue without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 561
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

Aftercare with CC/MCC

Facility

$70,400.00

Service Code	MSDRG 949
Min. Negotiated Rate	$28,531.63
Max. Negotiated Rate	$31,701.81
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$31,701.81
Rate for Payer: American Health Plans Medicare Advantage	$31,701.81
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$31,701.81
Rate for Payer: CIGNA Medicare Advantage	$31,701.81
Rate for Payer: HealthChoice Utah Medicare Advantage	$31,701.81
Rate for Payer: Humana Medicare Advantage	$31,701.81
Rate for Payer: Medicare	$31,701.81
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$31,701.81
Rate for Payer: MOLINA MEDICARE	$31,701.81
Rate for Payer: Pacific Source Medicare Advantage	$31,701.81
Rate for Payer: Select Health Medicare Advantage	$31,701.81
Rate for Payer: SELF PAY	$35,200.00
Rate for Payer: Tricare West Military	$28,531.63

Aftercare without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 950
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

Know your out-of-pocket cost for care.

All Charges