Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

OPSITE FLEX 4X4.75 WP

Facility

$2.38

Hospital Revenue Code	270
Min. Negotiated Rate	$1.19
Max. Negotiated Rate	$1.19
Rate for Payer: SELF PAY	$1.19

OPSITE IV3000 2 3/8"

Facility

$0.52

Hospital Revenue Code	270
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.26
Rate for Payer: SELF PAY	$0.26

OPSITE IV3000 2 3/8" WP

Facility

$0.52

Hospital Revenue Code	270
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.26
Rate for Payer: SELF PAY	$0.26

OPTICELL AG+ SILVER

Facility

$17.94

Hospital Revenue Code	270
Min. Negotiated Rate	$8.97
Max. Negotiated Rate	$8.97
Rate for Payer: SELF PAY	$8.97

OPTICELL AG+ SILVER WP

Facility

$17.94

Hospital Revenue Code	270
Min. Negotiated Rate	$8.97
Max. Negotiated Rate	$8.97
Rate for Payer: SELF PAY	$8.97

ORAL SUCTION NEO/PED 10 FR

Facility

$4.38

Hospital Revenue Code	270
Min. Negotiated Rate	$2.19
Max. Negotiated Rate	$2.19
Rate for Payer: SELF PAY	$2.19

Orbital procedures with CC/MCC

Facility

$102,400.00

Service Code	MSDRG 113
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

Orbital procedures without CC/MCC

Facility

$86,400.00

Service Code	MSDRG 114
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

O.R. procedures for obesity with CC

Facility

$99,200.00

Service Code	MSDRG 620
Min. Negotiated Rate	$59,897.93
Max. Negotiated Rate	$66,553.26
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$66,553.26
Rate for Payer: American Health Plans Medicare Advantage	$66,553.26
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$66,553.26
Rate for Payer: CIGNA Medicare Advantage	$66,553.26
Rate for Payer: HealthChoice Utah Medicare Advantage	$66,553.26
Rate for Payer: Humana Medicare Advantage	$66,553.26
Rate for Payer: Medicare	$66,553.26
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$66,553.26
Rate for Payer: MOLINA MEDICARE	$66,553.26
Rate for Payer: Pacific Source Medicare Advantage	$66,553.26
Rate for Payer: Select Health Medicare Advantage	$66,553.26
Rate for Payer: SELF PAY	$49,600.00
Rate for Payer: Tricare West Military	$59,897.93

O.R. procedures for obesity with MCC

Facility

$112,000.00

Service Code	MSDRG 619
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

O.R. procedures for obesity without CC/MCC

Facility

$99,200.00

Service Code	MSDRG 621
Min. Negotiated Rate	$59,897.93
Max. Negotiated Rate	$66,553.26
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$66,553.26
Rate for Payer: American Health Plans Medicare Advantage	$66,553.26
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$66,553.26
Rate for Payer: CIGNA Medicare Advantage	$66,553.26
Rate for Payer: HealthChoice Utah Medicare Advantage	$66,553.26
Rate for Payer: Humana Medicare Advantage	$66,553.26
Rate for Payer: Medicare	$66,553.26
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$66,553.26
Rate for Payer: MOLINA MEDICARE	$66,553.26
Rate for Payer: Pacific Source Medicare Advantage	$66,553.26
Rate for Payer: Select Health Medicare Advantage	$66,553.26
Rate for Payer: SELF PAY	$49,600.00
Rate for Payer: Tricare West Military	$59,897.93

O.R. procedures with diagnoses of other contact with health services with CC*

Facility

$115,200.00

Service Code	MSDRG 940
Min. Negotiated Rate	$53,247.52
Max. Negotiated Rate	$59,163.91
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$59,163.91
Rate for Payer: American Health Plans Medicare Advantage	$59,163.91
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$59,163.91
Rate for Payer: CIGNA Medicare Advantage	$59,163.91
Rate for Payer: HealthChoice Utah Medicare Advantage	$59,163.91
Rate for Payer: Humana Medicare Advantage	$59,163.91
Rate for Payer: Medicare	$59,163.91
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$59,163.91
Rate for Payer: MOLINA MEDICARE	$59,163.91
Rate for Payer: Pacific Source Medicare Advantage	$59,163.91
Rate for Payer: Select Health Medicare Advantage	$59,163.91
Rate for Payer: SELF PAY	$57,600.00
Rate for Payer: Tricare West Military	$53,247.52

O.R. procedures with diagnoses of other contact with health services with MCC*

Facility

$115,200.00

Service Code	MSDRG 939
Min. Negotiated Rate	$53,247.52
Max. Negotiated Rate	$59,163.91
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$59,163.91
Rate for Payer: American Health Plans Medicare Advantage	$59,163.91
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$59,163.91
Rate for Payer: CIGNA Medicare Advantage	$59,163.91
Rate for Payer: HealthChoice Utah Medicare Advantage	$59,163.91
Rate for Payer: Humana Medicare Advantage	$59,163.91
Rate for Payer: Medicare	$59,163.91
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$59,163.91
Rate for Payer: MOLINA MEDICARE	$59,163.91
Rate for Payer: Pacific Source Medicare Advantage	$59,163.91
Rate for Payer: Select Health Medicare Advantage	$59,163.91
Rate for Payer: SELF PAY	$57,600.00
Rate for Payer: Tricare West Military	$53,247.52

O.R. procedures with diagnoses of other contact with health services without CC/MCC

Facility

$115,200.00

Service Code	MSDRG 941
Min. Negotiated Rate	$53,247.52
Max. Negotiated Rate	$59,163.91
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$59,163.91
Rate for Payer: American Health Plans Medicare Advantage	$59,163.91
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$59,163.91
Rate for Payer: CIGNA Medicare Advantage	$59,163.91
Rate for Payer: HealthChoice Utah Medicare Advantage	$59,163.91
Rate for Payer: Humana Medicare Advantage	$59,163.91
Rate for Payer: Medicare	$59,163.91
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$59,163.91
Rate for Payer: MOLINA MEDICARE	$59,163.91
Rate for Payer: Pacific Source Medicare Advantage	$59,163.91
Rate for Payer: Select Health Medicare Advantage	$59,163.91
Rate for Payer: SELF PAY	$57,600.00
Rate for Payer: Tricare West Military	$53,247.52

Orthotics - 1 Unit

Facility

$55.00

Service Code	CPT 97760
Hospital Revenue Code	430
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$27.50
Rate for Payer: SELF PAY	$27.50

Ortopad Eye Patch

Facility

$1.62

Hospital Revenue Code	270
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$0.81
Rate for Payer: SELF PAY	$0.81

OSMOLALITY SERUM

Facility

$36.00

Service Code	CPT 83930
Hospital Revenue Code	300
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$18.00
Rate for Payer: SELF PAY	$18.00

Osmolite WP

Facility

$7.88

Hospital Revenue Code	270
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$3.94
Rate for Payer: SELF PAY	$3.94

Osteomyelitis with CC

Facility

$80,000.00

Service Code	MSDRG 540
Min. Negotiated Rate	$31,949.32
Max. Negotiated Rate	$35,499.24
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$35,499.24
Rate for Payer: American Health Plans Medicare Advantage	$35,499.24
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$35,499.24
Rate for Payer: CIGNA Medicare Advantage	$35,499.24
Rate for Payer: HealthChoice Utah Medicare Advantage	$35,499.24
Rate for Payer: Humana Medicare Advantage	$35,499.24
Rate for Payer: Medicare	$35,499.24
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$35,499.24
Rate for Payer: MOLINA MEDICARE	$35,499.24
Rate for Payer: Pacific Source Medicare Advantage	$35,499.24
Rate for Payer: Select Health Medicare Advantage	$35,499.24
Rate for Payer: SELF PAY	$40,000.00
Rate for Payer: Tricare West Military	$31,949.32

Osteomyelitis with MCC

Facility

$89,600.00

Service Code	MSDRG 539
Min. Negotiated Rate	$38,877.17
Max. Negotiated Rate	$43,196.85
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$43,196.85
Rate for Payer: American Health Plans Medicare Advantage	$43,196.85
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$43,196.85
Rate for Payer: CIGNA Medicare Advantage	$43,196.85
Rate for Payer: HealthChoice Utah Medicare Advantage	$43,196.85
Rate for Payer: Humana Medicare Advantage	$43,196.85
Rate for Payer: Medicare	$43,196.85
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$43,196.85
Rate for Payer: MOLINA MEDICARE	$43,196.85
Rate for Payer: Pacific Source Medicare Advantage	$43,196.85
Rate for Payer: Select Health Medicare Advantage	$43,196.85
Rate for Payer: SELF PAY	$44,800.00
Rate for Payer: Tricare West Military	$38,877.17

Osteomyelitis without CC/MCC

Facility

$70,400.00

Service Code	MSDRG 541
Min. Negotiated Rate	$31,579.40
Max. Negotiated Rate	$35,088.22
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$35,088.22
Rate for Payer: American Health Plans Medicare Advantage	$35,088.22
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$35,088.22
Rate for Payer: CIGNA Medicare Advantage	$35,088.22
Rate for Payer: HealthChoice Utah Medicare Advantage	$35,088.22
Rate for Payer: Humana Medicare Advantage	$35,088.22
Rate for Payer: Medicare	$35,088.22
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$35,088.22
Rate for Payer: MOLINA MEDICARE	$35,088.22
Rate for Payer: Pacific Source Medicare Advantage	$35,088.22
Rate for Payer: Select Health Medicare Advantage	$35,088.22
Rate for Payer: SELF PAY	$35,200.00
Rate for Payer: Tricare West Military	$31,579.40

Ostomy Barrier Sensura Mio Cli

Facility

$9.50

Hospital Revenue Code	270
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$4.75
Rate for Payer: SELF PAY	$4.75

OSTOMY BARRIER STRIP PASTE BRA

Facility

$2.08

Hospital Revenue Code	270
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$1.04
Rate for Payer: SELF PAY	$1.04
Rate for Payer: SELF PAY	$1.10

OSTOMY LITTLE ONES POUCH

Facility

$3.00

Hospital Revenue Code	270
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$1.50
Rate for Payer: SELF PAY	$1.50

OSTOMY LITTLE ONES WAFER 31MM

Facility

$6.58

Hospital Revenue Code	270
Min. Negotiated Rate	$3.29
Max. Negotiated Rate	$3.29
Rate for Payer: SELF PAY	$3.29

Know your out-of-pocket cost for care.

All Charges