Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

Peritoneal adhesiolysis with MCC

Facility

$76,800.00

Service Code	MSDRG 335
Min. Negotiated Rate	$38,828.92
Max. Negotiated Rate	$43,143.24
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$43,143.24
Rate for Payer: American Health Plans Medicare Advantage	$43,143.24
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$43,143.24
Rate for Payer: CIGNA Medicare Advantage	$43,143.24
Rate for Payer: HealthChoice Utah Medicare Advantage	$43,143.24
Rate for Payer: Humana Medicare Advantage	$43,143.24
Rate for Payer: Medicare	$43,143.24
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$43,143.24
Rate for Payer: MOLINA MEDICARE	$43,143.24
Rate for Payer: Pacific Source Medicare Advantage	$43,143.24
Rate for Payer: Select Health Medicare Advantage	$43,143.24
Rate for Payer: SELF PAY	$38,400.00
Rate for Payer: Tricare West Military	$38,828.92

Peritoneal adhesiolysis without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 337
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

Permanent cardiac pacemaker implant with CC

Facility

$112,000.00

Service Code	MSDRG 243
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

Permanent cardiac pacemaker implant with MCC

Facility

$112,000.00

Service Code	MSDRG 242
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

Permanent cardiac pacemaker implant without CC/MCC

Facility

$112,000.00

Service Code	MSDRG 244
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

PFR95 SURGICAL MASK

Facility

$289.12

Hospital Revenue Code	270
Min. Negotiated Rate	$144.56
Max. Negotiated Rate	$144.56
Rate for Payer: SELF PAY	$144.56

PFS 1000mL KANGAROO E

Facility

$4.80

Hospital Revenue Code	270
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$2.40
Rate for Payer: SELF PAY	$2.40

PFS 1000mL KANGAROO E WP

Facility

$4.80

Hospital Revenue Code	270
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$2.40
Rate for Payer: SELF PAY	$2.40

PHENOBARB LEVEL

Facility

$15.30

Service Code	CPT 80184
Hospital Revenue Code	300
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$7.65
Rate for Payer: SELF PAY	$7.65

PHOSPHORUS

Facility

$28.00

Service Code	CPT 84100
Hospital Revenue Code	300
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$14.00
Rate for Payer: SELF PAY	$14.00

PICC LINE DRESSING

Facility

$24.00

Hospital Revenue Code	270
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$12.00
Rate for Payer: SELF PAY	$12.00

PICC LINE DRESSING WP

Facility

$24.00

Hospital Revenue Code	270
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$12.00
Rate for Payer: SELF PAY	$12.00

Piggyback ETCO2 Sample Cannula

Facility

$23.02

Hospital Revenue Code	270
Min. Negotiated Rate	$11.51
Max. Negotiated Rate	$11.51
Rate for Payer: SELF PAY	$11.51

PIVOT 1.5

Facility

$22.80

Hospital Revenue Code	270
Min. Negotiated Rate	$11.40
Max. Negotiated Rate	$11.40
Rate for Payer: SELF PAY	$11.40

PIVOT 1.5 8OZ

Facility

$13.22

Hospital Revenue Code	270
Min. Negotiated Rate	$6.61
Max. Negotiated Rate	$6.61
Rate for Payer: SELF PAY	$6.61

PIVOT 1.5 WP

Facility

$22.80

Hospital Revenue Code	270
Min. Negotiated Rate	$11.40
Max. Negotiated Rate	$11.40
Rate for Payer: SELF PAY	$11.40

PLATELET COUNT

Facility

$4.48

Service Code	CPT 85049
Hospital Revenue Code	300
Min. Negotiated Rate	$2.24
Max. Negotiated Rate	$2.24
Rate for Payer: SELF PAY	$2.24

Pleural effusion with CC

Facility

$60,800.00

Service Code	MSDRG 187
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

Pleural effusion with MCC

Facility

$67,200.00

Service Code	MSDRG 186
Min. Negotiated Rate	$34,719.65
Max. Negotiated Rate	$38,577.39
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$38,577.39
Rate for Payer: American Health Plans Medicare Advantage	$38,577.39
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$38,577.39
Rate for Payer: CIGNA Medicare Advantage	$38,577.39
Rate for Payer: HealthChoice Utah Medicare Advantage	$38,577.39
Rate for Payer: Humana Medicare Advantage	$38,577.39
Rate for Payer: Medicare	$38,577.39
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$38,577.39
Rate for Payer: MOLINA MEDICARE	$38,577.39
Rate for Payer: Pacific Source Medicare Advantage	$38,577.39
Rate for Payer: Select Health Medicare Advantage	$38,577.39
Rate for Payer: SELF PAY	$33,600.00
Rate for Payer: Tricare West Military	$34,719.65

Pleural effusion without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 188
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

Pleur-Evac Sahara

Facility

$270.12

Hospital Revenue Code	270
Min. Negotiated Rate	$135.06
Max. Negotiated Rate	$135.06
Rate for Payer: SELF PAY	$135.06

PLV

Facility

$350.00

Hospital Revenue Code	320
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$175.00
Rate for Payer: SELF PAY	$175.00

Pneumothorax with CC

Facility

$51,200.00

Service Code	MSDRG 200
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

Pneumothorax with MCC

Facility

$86,400.00

Service Code	MSDRG 199
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

Pneumothorax without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 201
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.

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