Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

MEDELA DOUBLE LUMEN TUBING

Facility

$36.00

Hospital Revenue Code	270
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$18.00
Rate for Payer: SELF PAY	$18.00

MEDELA FITPAD

Facility

$23.48

Hospital Revenue Code	270
Min. Negotiated Rate	$11.74
Max. Negotiated Rate	$11.74
Rate for Payer: SELF PAY	$11.74

MEDELA FOAM KIT MEDIUM

Facility

$78.26

Hospital Revenue Code	270
Min. Negotiated Rate	$39.13
Max. Negotiated Rate	$39.13
Rate for Payer: SELF PAY	$39.13

MEDELA Y QUICK CONNECT

Facility

$64.16

Hospital Revenue Code	270
Min. Negotiated Rate	$32.08
Max. Negotiated Rate	$32.08
Rate for Payer: SELF PAY	$32.08

MEDICAL ADHESIVE

Facility

$46.94

Hospital Revenue Code	270
Min. Negotiated Rate	$23.47
Max. Negotiated Rate	$23.47
Rate for Payer: SELF PAY	$23.47

Medical back problems with MCC*

Facility

$83,200.00

Service Code	MSDRG 551
Min. Negotiated Rate	$37,469.88
Max. Negotiated Rate	$41,633.20
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$41,633.20
Rate for Payer: American Health Plans Medicare Advantage	$41,633.20
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$41,633.20
Rate for Payer: CIGNA Medicare Advantage	$41,633.20
Rate for Payer: HealthChoice Utah Medicare Advantage	$41,633.20
Rate for Payer: Humana Medicare Advantage	$41,633.20
Rate for Payer: Medicare	$41,633.20
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$41,633.20
Rate for Payer: MOLINA MEDICARE	$41,633.20
Rate for Payer: Pacific Source Medicare Advantage	$41,633.20
Rate for Payer: Select Health Medicare Advantage	$41,633.20
Rate for Payer: SELF PAY	$41,600.00
Rate for Payer: Tricare West Military	$37,469.88

Medical back problems without MCC*

Facility

$83,200.00

Service Code	MSDRG 552
Min. Negotiated Rate	$36,533.03
Max. Negotiated Rate	$40,592.26
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$40,592.26
Rate for Payer: American Health Plans Medicare Advantage	$40,592.26
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$40,592.26
Rate for Payer: CIGNA Medicare Advantage	$40,592.26
Rate for Payer: HealthChoice Utah Medicare Advantage	$40,592.26
Rate for Payer: Humana Medicare Advantage	$40,592.26
Rate for Payer: Medicare	$40,592.26
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$40,592.26
Rate for Payer: MOLINA MEDICARE	$40,592.26
Rate for Payer: Pacific Source Medicare Advantage	$40,592.26
Rate for Payer: Select Health Medicare Advantage	$40,592.26
Rate for Payer: SELF PAY	$41,600.00
Rate for Payer: Tricare West Military	$36,533.03

MEDIUM SPU WRAP VEST

Facility

$135.20

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

Menstrual and other female reproductive system disorders with CC/MCC

Facility

$51,200.00

Service Code	MSDRG 760
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

Menstrual and other female reproductive system disorders without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 761
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

MEPILEX AG 6x6

Facility

$50.78

Hospital Revenue Code	270
Min. Negotiated Rate	$25.39
Max. Negotiated Rate	$25.39
Rate for Payer: SELF PAY	$25.39

MEPILEX TRANSFER 6x8

Facility

$16.60

Hospital Revenue Code	270
Min. Negotiated Rate	$8.30
Max. Negotiated Rate	$8.30
Rate for Payer: SELF PAY	$8.30

MESALT CLEANSING DRESSING 20%

Facility

$2.04

Hospital Revenue Code	270
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.02
Rate for Payer: SELF PAY	$1.02

MIC-KEY ENFIT BUTTON 12FR 0.8

Facility

$259.26

Hospital Revenue Code	270
Min. Negotiated Rate	$129.63
Max. Negotiated Rate	$129.63
Rate for Payer: SELF PAY	$129.63

MIC-KEY ENFIT BUTTON 12FR 1.0

Facility

$259.26

Hospital Revenue Code	270
Min. Negotiated Rate	$129.63
Max. Negotiated Rate	$129.63
Rate for Payer: SELF PAY	$129.63

MIC-KEY ENFIT BUTTON 12FR 1.2

Facility

$231.52

Hospital Revenue Code	270
Min. Negotiated Rate	$115.76
Max. Negotiated Rate	$115.76
Rate for Payer: SELF PAY	$115.76

MIC-KEY ENFIT BUTTON 12FR 1.5

Facility

$259.26

Hospital Revenue Code	270
Min. Negotiated Rate	$129.63
Max. Negotiated Rate	$129.63
Rate for Payer: SELF PAY	$129.63

MIC-KEY ENFIT BUTTON 14FR 1.0

Facility

$280.62

Hospital Revenue Code	270
Min. Negotiated Rate	$140.31
Max. Negotiated Rate	$140.31
Rate for Payer: SELF PAY	$140.31

MIC-KEY ENFIT BUTTON 14FR 1.2

Facility

$280.62

Hospital Revenue Code	270
Min. Negotiated Rate	$140.31
Max. Negotiated Rate	$140.31
Rate for Payer: SELF PAY	$140.31

MIC-KEY ENFIT BUTTON 14FR 1.5

Facility

$259.26

Hospital Revenue Code	270
Min. Negotiated Rate	$129.63
Max. Negotiated Rate	$129.63
Rate for Payer: SELF PAY	$129.63

MIC-KEY ENFIT BUTTON 14FR 1.7

Facility

$259.26

Hospital Revenue Code	270
Min. Negotiated Rate	$129.63
Max. Negotiated Rate	$129.63
Rate for Payer: SELF PAY	$129.63

MIC-KEY ENFIT BUTTON 14FR 2.0

Facility

$231.52

Hospital Revenue Code	270
Min. Negotiated Rate	$115.76
Max. Negotiated Rate	$115.76
Rate for Payer: SELF PAY	$115.76

MIC-KEY ENFIT BUTTON 14FR 2.3

Facility

$231.52

Hospital Revenue Code	270
Min. Negotiated Rate	$115.76
Max. Negotiated Rate	$115.76
Rate for Payer: SELF PAY	$115.76

MIC-KEY ENFIT BUTTON 14FR 2.5

Facility

$231.52

Hospital Revenue Code	270
Min. Negotiated Rate	$115.76
Max. Negotiated Rate	$115.76
Rate for Payer: SELF PAY	$115.76

MIC-KEY ENFIT BUTTON 14FR 3.0

Facility

$208.02

Hospital Revenue Code	270
Min. Negotiated Rate	$104.01
Max. Negotiated Rate	$104.01
Rate for Payer: SELF PAY	$104.01

Know your out-of-pocket cost for care.

All Charges