Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

MIC-KEY ENFIT BUTTON 14FR 3.5

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 16FR 1.0

Facility

$347.30

Hospital Revenue Code	270
Min. Negotiated Rate	$173.65
Max. Negotiated Rate	$173.65
Rate for Payer: SELF PAY	$173.65

MIC-KEY ENFIT BUTTON 16FR 1.2

Facility

$260.20

Hospital Revenue Code	270
Min. Negotiated Rate	$130.10
Max. Negotiated Rate	$130.10
Rate for Payer: SELF PAY	$130.10

MIC-KEY ENFIT BUTTON 16FR 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 18FR 0.8

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 18FR 1.0

Facility

$209.14

Hospital Revenue Code	270
Min. Negotiated Rate	$104.57
Max. Negotiated Rate	$104.57
Rate for Payer: SELF PAY	$104.57

MIC-KEY ENFIT BUTTON 18FR 1.2

Facility

$266.06

Hospital Revenue Code	270
Min. Negotiated Rate	$133.03
Max. Negotiated Rate	$133.03
Rate for Payer: SELF PAY	$133.03

MIC-KEY ENFIT BUTTON 18FR 1.5

Facility

$208.02

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

MIC-KEY ENFIT BUTTON 18FR 1.7

Facility

$315.38

Hospital Revenue Code	270
Min. Negotiated Rate	$157.69
Max. Negotiated Rate	$157.69
Rate for Payer: SELF PAY	$157.69

MIC-KEY ENFIT BUTTON 18FR 2.0

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 18FR 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 20FR 1.2

Facility

$235.04

Hospital Revenue Code	270
Min. Negotiated Rate	$117.52
Max. Negotiated Rate	$117.52
Rate for Payer: SELF PAY	$117.52

MICROALBUMIN CREATININE

Facility

$25.00

Service Code	CPT 82043
Hospital Revenue Code	300
Min. Negotiated Rate	$12.50
Max. Negotiated Rate	$12.50
Rate for Payer: SELF PAY	$12.50

Minor bladder procedures with CC

Facility

$60,800.00

Service Code	MSDRG 663
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

Minor bladder procedures with MCC

Facility

$112,000.00

Service Code	MSDRG 662
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

Minor bladder procedures without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 664
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

Minor skin disorders with MCC

Facility

$86,400.00

Service Code	MSDRG 606
Min. Negotiated Rate	$45,873.36
Max. Negotiated Rate	$50,970.40
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$50,970.40
Rate for Payer: American Health Plans Medicare Advantage	$50,970.40
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$50,970.40
Rate for Payer: CIGNA Medicare Advantage	$50,970.40
Rate for Payer: HealthChoice Utah Medicare Advantage	$50,970.40
Rate for Payer: Humana Medicare Advantage	$50,970.40
Rate for Payer: Medicare	$50,970.40
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$50,970.40
Rate for Payer: MOLINA MEDICARE	$50,970.40
Rate for Payer: Pacific Source Medicare Advantage	$50,970.40
Rate for Payer: Select Health Medicare Advantage	$50,970.40
Rate for Payer: SELF PAY	$43,200.00
Rate for Payer: Tricare West Military	$45,873.36

Minor skin disorders without MCC

Facility

$60,800.00

Service Code	MSDRG 607
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

Minor small and large bowel procedures with CC

Facility

$64,000.00

Service Code	MSDRG 345
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

Minor small and large bowel procedures with MCC

Facility

$112,000.00

Service Code	MSDRG 344
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

Minor small and large bowel procedures without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 346
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

Miscellaneous disorders of nutrition, metabolism, fluids and electrolytes with MCC

Facility

$70,400.00

Service Code	MSDRG 640
Min. Negotiated Rate	$32,049.84
Max. Negotiated Rate	$35,610.93
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$35,610.93
Rate for Payer: American Health Plans Medicare Advantage	$35,610.93
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$35,610.93
Rate for Payer: CIGNA Medicare Advantage	$35,610.93
Rate for Payer: HealthChoice Utah Medicare Advantage	$35,610.93
Rate for Payer: Humana Medicare Advantage	$35,610.93
Rate for Payer: Medicare	$35,610.93
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$35,610.93
Rate for Payer: MOLINA MEDICARE	$35,610.93
Rate for Payer: Pacific Source Medicare Advantage	$35,610.93
Rate for Payer: Select Health Medicare Advantage	$35,610.93
Rate for Payer: SELF PAY	$35,200.00
Rate for Payer: Tricare West Military	$32,049.84

Miscellaneous disorders of nutrition, metabolism, fluids and electrolytes without MCC

Facility

$57,600.00

Service Code	MSDRG 641
Min. Negotiated Rate	$27,618.91
Max. Negotiated Rate	$30,687.68
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$30,687.68
Rate for Payer: American Health Plans Medicare Advantage	$30,687.68
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$30,687.68
Rate for Payer: CIGNA Medicare Advantage	$30,687.68
Rate for Payer: HealthChoice Utah Medicare Advantage	$30,687.68
Rate for Payer: Humana Medicare Advantage	$30,687.68
Rate for Payer: Medicare	$30,687.68
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$30,687.68
Rate for Payer: MOLINA MEDICARE	$30,687.68
Rate for Payer: Pacific Source Medicare Advantage	$30,687.68
Rate for Payer: Select Health Medicare Advantage	$30,687.68
Rate for Payer: SELF PAY	$28,800.00
Rate for Payer: Tricare West Military	$27,618.91

Moderate Complexity Eval

Facility

$111.00

Service Code	CPT 97162
Hospital Revenue Code	420
Min. Negotiated Rate	$55.50
Max. Negotiated Rate	$55.50
Rate for Payer: SELF PAY	$55.50

Moderate Complexity Evaluation

Facility

$111.00

Hospital Revenue Code	430
Min. Negotiated Rate	$55.50
Max. Negotiated Rate	$55.50
Rate for Payer: SELF PAY	$55.50

Know your out-of-pocket cost for care.

All Charges