Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

Other injury, poisoning and toxic effect diagnoses without MCC*

Facility

$60,800.00

Service Code	MSDRG 923
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

Other kidney and urinary tract diagnoses with CC

Facility

$60,800.00

Service Code	MSDRG 699
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

Other kidney and urinary tract diagnoses with MCC

Facility

$70,400.00

Service Code	MSDRG 698
Min. Negotiated Rate	$36,227.45
Max. Negotiated Rate	$40,252.72
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$40,252.72
Rate for Payer: American Health Plans Medicare Advantage	$40,252.72
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$40,252.72
Rate for Payer: CIGNA Medicare Advantage	$40,252.72
Rate for Payer: HealthChoice Utah Medicare Advantage	$40,252.72
Rate for Payer: Humana Medicare Advantage	$40,252.72
Rate for Payer: Medicare	$40,252.72
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$40,252.72
Rate for Payer: MOLINA MEDICARE	$40,252.72
Rate for Payer: Pacific Source Medicare Advantage	$40,252.72
Rate for Payer: Select Health Medicare Advantage	$40,252.72
Rate for Payer: SELF PAY	$35,200.00
Rate for Payer: Tricare West Military	$36,227.45

Other kidney and urinary tract diagnoses without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 700
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

Other kidney and urinary tract procedures with CC

Facility

$70,400.00

Service Code	MSDRG 674
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

Other kidney and urinary tract procedures with MCC

Facility

$99,200.00

Service Code	MSDRG 673
Min. Negotiated Rate	$52,688.63
Max. Negotiated Rate	$58,542.92
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$58,542.92
Rate for Payer: American Health Plans Medicare Advantage	$58,542.92
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$58,542.92
Rate for Payer: CIGNA Medicare Advantage	$58,542.92
Rate for Payer: HealthChoice Utah Medicare Advantage	$58,542.92
Rate for Payer: Humana Medicare Advantage	$58,542.92
Rate for Payer: Medicare	$58,542.92
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$58,542.92
Rate for Payer: MOLINA MEDICARE	$58,542.92
Rate for Payer: Pacific Source Medicare Advantage	$58,542.92
Rate for Payer: Select Health Medicare Advantage	$58,542.92
Rate for Payer: SELF PAY	$49,600.00
Rate for Payer: Tricare West Military	$52,688.63

Other kidney and urinary tract procedures without CC/MCC

Facility

$70,400.00

Service Code	MSDRG 675
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

Other major cardiovascular procedures with CC

Facility

$112,000.00

Service Code	MSDRG 271
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

Other major cardiovascular procedures with MCC

Facility

$112,000.00

Service Code	MSDRG 270
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

Other major cardiovascular procedures without CC/MCC

Facility

$112,000.00

Service Code	MSDRG 272
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

Other male reproductive system diagnoses with CC/MCC

Facility

$60,800.00

Service Code	MSDRG 729
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

Other male reproductive system diagnoses without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 730
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

Other male reproductive system O.R. procedures except malignancy with CC/MCC

Facility

$86,400.00

Service Code	MSDRG 717
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

Other male reproductive system O.R. procedures except malignancy without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 718
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

Other male reproductive system O.R. procedures for malignancy with CC/MCC

Facility

$60,800.00

Service Code	MSDRG 715
Min. Negotiated Rate	$26,010.59
Max. Negotiated Rate	$28,900.65
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$28,900.65
Rate for Payer: American Health Plans Medicare Advantage	$28,900.65
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$28,900.65
Rate for Payer: CIGNA Medicare Advantage	$28,900.65
Rate for Payer: HealthChoice Utah Medicare Advantage	$28,900.65
Rate for Payer: Humana Medicare Advantage	$28,900.65
Rate for Payer: Medicare	$28,900.65
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$28,900.65
Rate for Payer: MOLINA MEDICARE	$28,900.65
Rate for Payer: Pacific Source Medicare Advantage	$28,900.65
Rate for Payer: Select Health Medicare Advantage	$28,900.65
Rate for Payer: SELF PAY	$30,400.00
Rate for Payer: Tricare West Military	$26,010.59

Other male reproductive system O.R. procedures for malignancy without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 716
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

Other multiple significant trauma with CC

Facility

$86,400.00

Service Code	MSDRG 964
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

Other multiple significant trauma with MCC

Facility

$86,400.00

Service Code	MSDRG 963
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

Other multiple significant trauma without CC/MCC

Facility

$86,400.00

Service Code	MSDRG 965
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

Other musculoskeletal system and connective tissue diagnoses with CC

Facility

$70,400.00

Service Code	MSDRG 565
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

Other musculoskeletal system and connective tissue diagnoses with MCC

Facility

$67,200.00

Service Code	MSDRG 564
Min. Negotiated Rate	$35,266.48
Max. Negotiated Rate	$39,184.98
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$39,184.98
Rate for Payer: American Health Plans Medicare Advantage	$39,184.98
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$39,184.98
Rate for Payer: CIGNA Medicare Advantage	$39,184.98
Rate for Payer: HealthChoice Utah Medicare Advantage	$39,184.98
Rate for Payer: Humana Medicare Advantage	$39,184.98
Rate for Payer: Medicare	$39,184.98
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$39,184.98
Rate for Payer: MOLINA MEDICARE	$39,184.98
Rate for Payer: Pacific Source Medicare Advantage	$39,184.98
Rate for Payer: Select Health Medicare Advantage	$39,184.98
Rate for Payer: SELF PAY	$33,600.00
Rate for Payer: Tricare West Military	$35,266.48

Other musculoskeletal system and connective tissue diagnoses without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 566
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

Other musculoskeletal system and connective tissue O.R. procedures with CC*

Facility

$96,000.00

Service Code	MSDRG 516
Min. Negotiated Rate	$47,083.63
Max. Negotiated Rate	$52,315.14
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$52,315.14
Rate for Payer: American Health Plans Medicare Advantage	$52,315.14
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$52,315.14
Rate for Payer: CIGNA Medicare Advantage	$52,315.14
Rate for Payer: HealthChoice Utah Medicare Advantage	$52,315.14
Rate for Payer: Humana Medicare Advantage	$52,315.14
Rate for Payer: Medicare	$52,315.14
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$52,315.14
Rate for Payer: MOLINA MEDICARE	$52,315.14
Rate for Payer: Pacific Source Medicare Advantage	$52,315.14
Rate for Payer: Select Health Medicare Advantage	$52,315.14
Rate for Payer: SELF PAY	$48,000.00
Rate for Payer: Tricare West Military	$47,083.63

Other musculoskeletal system and connective tissue O.R. procedures with MCC*

Facility

$96,000.00

Service Code	MSDRG 515
Min. Negotiated Rate	$47,083.63
Max. Negotiated Rate	$52,315.14
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$52,315.14
Rate for Payer: American Health Plans Medicare Advantage	$52,315.14
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$52,315.14
Rate for Payer: CIGNA Medicare Advantage	$52,315.14
Rate for Payer: HealthChoice Utah Medicare Advantage	$52,315.14
Rate for Payer: Humana Medicare Advantage	$52,315.14
Rate for Payer: Medicare	$52,315.14
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$52,315.14
Rate for Payer: MOLINA MEDICARE	$52,315.14
Rate for Payer: Pacific Source Medicare Advantage	$52,315.14
Rate for Payer: Select Health Medicare Advantage	$52,315.14
Rate for Payer: SELF PAY	$48,000.00
Rate for Payer: Tricare West Military	$47,083.63

Other musculoskeletal system and connective tissue O.R. procedures without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 517
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