Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

AICD generator procedures

Facility

$96,000.00

Service Code	MSDRG 245
Min. Negotiated Rate	$48,792.46
Max. Negotiated Rate	$54,213.85
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$54,213.85
Rate for Payer: American Health Plans Medicare Advantage	$54,213.85
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$54,213.85
Rate for Payer: CIGNA Medicare Advantage	$54,213.85
Rate for Payer: HealthChoice Utah Medicare Advantage	$54,213.85
Rate for Payer: Humana Medicare Advantage	$54,213.85
Rate for Payer: Medicare	$54,213.85
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$54,213.85
Rate for Payer: MOLINA MEDICARE	$54,213.85
Rate for Payer: Pacific Source Medicare Advantage	$54,213.85
Rate for Payer: Select Health Medicare Advantage	$54,213.85
Rate for Payer: SELF PAY	$48,000.00
Rate for Payer: Tricare West Military	$48,792.46

AICD lead procedures

Facility

$112,000.00

Service Code	MSDRG 265
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

AIR FLOW METER

Facility

$138.24

Hospital Revenue Code	270
Min. Negotiated Rate	$69.12
Max. Negotiated Rate	$69.12
Rate for Payer: SELF PAY	$69.12

AIRWAY ADAPTER STRAIGHT ADULT

Facility

$18.00

Hospital Revenue Code	270
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$9.00
Rate for Payer: SELF PAY	$9.00

AIRWAY ADAPTER STRAIGHT PEDIAT

Facility

$18.24

Hospital Revenue Code	270
Min. Negotiated Rate	$9.12
Max. Negotiated Rate	$9.12
Rate for Payer: SELF PAY	$9.12

ALANINE AMINOTRANSFEREASE

Facility

$7.00

Service Code	CPT 84460
Hospital Revenue Code	300
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$3.50
Rate for Payer: SELF PAY	$3.50

ALBUMIN

Facility

$3.16

Service Code	CPT 82040
Hospital Revenue Code	300
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$1.58
Rate for Payer: SELF PAY	$1.58

ALCOHOL, ISOPROPYL 70% 16OZ (1

Facility

$4.10

Hospital Revenue Code	270
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$2.05
Rate for Payer: SELF PAY	$2.05

ALCOHOL PREP PADS

Facility

$3.14

Hospital Revenue Code	270
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$1.57
Rate for Payer: SELF PAY	$1.57

ALCOHOL PREP PADS WP

Facility

$3.14

Hospital Revenue Code	270
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$1.57
Rate for Payer: SELF PAY	$1.57

ALFAMINO INFANT

Facility

$70.68

Hospital Revenue Code	270
Min. Negotiated Rate	$35.34
Max. Negotiated Rate	$35.34
Rate for Payer: SELF PAY	$35.34

ALFAMINO JR

Facility

$70.68

Hospital Revenue Code	270
Min. Negotiated Rate	$35.34
Max. Negotiated Rate	$35.34
Rate for Payer: SELF PAY	$35.34

ALKALINE PHOSPHATE

Facility

$3.16

Service Code	CPT 84075
Hospital Revenue Code	300
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$1.58
Rate for Payer: SELF PAY	$1.58

Allergic reactions with MCC

Facility

$60,800.00

Service Code	MSDRG 915
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

Allergic reactions without MCC

Facility

$51,200.00

Service Code	MSDRG 916
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

ALLEVYN DRESSING HEEL/ELBOW

Facility

$20.64

Hospital Revenue Code	270
Min. Negotiated Rate	$10.32
Max. Negotiated Rate	$10.32
Rate for Payer: SELF PAY	$10.32

ALLEVYN DRESSING HEEL/ELBOW WP

Facility

$20.64

Hospital Revenue Code	270
Min. Negotiated Rate	$10.32
Max. Negotiated Rate	$10.32
Rate for Payer: SELF PAY	$10.32

ALLEVYN TRACHEOSTOMY DRESSING

Facility

$17.54

Hospital Revenue Code	270
Min. Negotiated Rate	$8.77
Max. Negotiated Rate	$8.77
Rate for Payer: SELF PAY	$8.77

Allogeneic bone marrow transplant

Facility

$60,800.00

Service Code	MSDRG 14
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

ALT (SGPT)

Facility

$7.00

Service Code	CPT 84460
Hospital Revenue Code	300
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$3.50
Rate for Payer: SELF PAY	$3.50

ALWAYS LINERS

Facility

$3.98

Hospital Revenue Code	270
Min. Negotiated Rate	$1.99
Max. Negotiated Rate	$1.99
Rate for Payer: SELF PAY	$1.99

ALWAYS LINERS WP

Facility

$3.98

Hospital Revenue Code	270
Min. Negotiated Rate	$1.99
Max. Negotiated Rate	$1.99
Rate for Payer: SELF PAY	$1.99

AMBU BAG ADULT

Facility

$28.18

Hospital Revenue Code	270
Min. Negotiated Rate	$14.09
Max. Negotiated Rate	$14.09
Rate for Payer: SELF PAY	$14.09

AMBU BAG ADULT WP

Facility

$28.18

Hospital Revenue Code	270
Min. Negotiated Rate	$14.09
Max. Negotiated Rate	$14.09
Rate for Payer: SELF PAY	$14.09

AMBU BAG INFANT

Facility

$29.36

Hospital Revenue Code	270
Min. Negotiated Rate	$14.68
Max. Negotiated Rate	$14.68
Rate for Payer: SELF PAY	$14.68

Know your out-of-pocket cost for care.

All Charges