Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

POC CREATININE

Facility

$24.08

Service Code	CPT 82565
Hospital Revenue Code	300
Min. Negotiated Rate	$12.04
Max. Negotiated Rate	$12.04
Rate for Payer: SELF PAY	$12.04

Poisoning and toxic effects of drugs with MCC

Facility

$51,200.00

Service Code	MSDRG 917
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

Poisoning and toxic effects of drugs without MCC

Facility

$51,200.00

Service Code	MSDRG 918
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

Polar Ice Machine

Facility

$5.00

Hospital Revenue Code	290
Min. Negotiated Rate	$2.50
Max. Negotiated Rate	$2.50
Rate for Payer: SELF PAY	$2.50

Polycal

Facility

$18.82

Hospital Revenue Code	270
Min. Negotiated Rate	$9.41
Max. Negotiated Rate	$9.41
Rate for Payer: SELF PAY	$9.41

POLYMEM 4X4 DRESSING

Facility

$12.66

Hospital Revenue Code	270
Min. Negotiated Rate	$6.33
Max. Negotiated Rate	$6.33
Rate for Payer: SELF PAY	$6.33

POLYMEM 4X4 DRESSING WP

Facility

$12.66

Hospital Revenue Code	270
Min. Negotiated Rate	$6.33
Max. Negotiated Rate	$6.33
Rate for Payer: SELF PAY	$6.33

PORTEX TRACH 7.5

Facility

$130.00

Hospital Revenue Code	270
Min. Negotiated Rate	$65.00
Max. Negotiated Rate	$65.00
Rate for Payer: SELF PAY	$65.00

Postoperative and post-traumatic infections with MCC

Facility

$76,800.00

Service Code	MSDRG 862
Min. Negotiated Rate	$37,196.47
Max. Negotiated Rate	$41,329.41
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$41,329.41
Rate for Payer: American Health Plans Medicare Advantage	$41,329.41
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$41,329.41
Rate for Payer: CIGNA Medicare Advantage	$41,329.41
Rate for Payer: HealthChoice Utah Medicare Advantage	$41,329.41
Rate for Payer: Humana Medicare Advantage	$41,329.41
Rate for Payer: Medicare	$41,329.41
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$41,329.41
Rate for Payer: MOLINA MEDICARE	$41,329.41
Rate for Payer: Pacific Source Medicare Advantage	$41,329.41
Rate for Payer: Select Health Medicare Advantage	$41,329.41
Rate for Payer: SELF PAY	$38,400.00
Rate for Payer: Tricare West Military	$37,196.47

Postoperative and post-traumatic infections without MCC

Facility

$60,800.00

Service Code	MSDRG 863
Min. Negotiated Rate	$24,848.58
Max. Negotiated Rate	$27,609.53
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$27,609.53
Rate for Payer: American Health Plans Medicare Advantage	$27,609.53
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$27,609.53
Rate for Payer: CIGNA Medicare Advantage	$27,609.53
Rate for Payer: HealthChoice Utah Medicare Advantage	$27,609.53
Rate for Payer: Humana Medicare Advantage	$27,609.53
Rate for Payer: Medicare	$27,609.53
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$27,609.53
Rate for Payer: MOLINA MEDICARE	$27,609.53
Rate for Payer: Pacific Source Medicare Advantage	$27,609.53
Rate for Payer: Select Health Medicare Advantage	$27,609.53
Rate for Payer: SELF PAY	$30,400.00
Rate for Payer: Tricare West Military	$24,848.58

Postoperative or post-traumatic infections with O.R. procedures with CC*

Facility

$102,400.00

Service Code	MSDRG 857
Min. Negotiated Rate	$50,191.70
Max. Negotiated Rate	$55,768.56
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$55,768.56
Rate for Payer: American Health Plans Medicare Advantage	$55,768.56
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$55,768.56
Rate for Payer: CIGNA Medicare Advantage	$55,768.56
Rate for Payer: HealthChoice Utah Medicare Advantage	$55,768.56
Rate for Payer: Humana Medicare Advantage	$55,768.56
Rate for Payer: Medicare	$55,768.56
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$55,768.56
Rate for Payer: MOLINA MEDICARE	$55,768.56
Rate for Payer: Pacific Source Medicare Advantage	$55,768.56
Rate for Payer: Select Health Medicare Advantage	$55,768.56
Rate for Payer: SELF PAY	$51,200.00
Rate for Payer: Tricare West Military	$50,191.70

Postoperative or post-traumatic infections with O.R. procedures with MCC*

Facility

$102,400.00

Service Code	MSDRG 856
Min. Negotiated Rate	$53,573.20
Max. Negotiated Rate	$59,525.78
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$59,525.78
Rate for Payer: American Health Plans Medicare Advantage	$59,525.78
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$59,525.78
Rate for Payer: CIGNA Medicare Advantage	$59,525.78
Rate for Payer: HealthChoice Utah Medicare Advantage	$59,525.78
Rate for Payer: Humana Medicare Advantage	$59,525.78
Rate for Payer: Medicare	$59,525.78
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$59,525.78
Rate for Payer: MOLINA MEDICARE	$59,525.78
Rate for Payer: Pacific Source Medicare Advantage	$59,525.78
Rate for Payer: Select Health Medicare Advantage	$59,525.78
Rate for Payer: SELF PAY	$51,200.00
Rate for Payer: Tricare West Military	$53,573.20

Postoperative or post-traumatic infections with O.R. procedures without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 858
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

Postpartum and post abortion diagnoses with O.R. procedures

Facility

$86,400.00

Service Code	MSDRG 769
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

Postpartum and post abortion diagnoses without O.R. procedures

Facility

$51,200.00

Service Code	MSDRG 776
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

POTASSIUM

Facility

$4.76

Service Code	CPT 84132
Hospital Revenue Code	300
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$2.38
Rate for Payer: SELF PAY	$2.38

PREALBUMIN

Facility

$14.59

Service Code	CPT 84134
Hospital Revenue Code	300
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$7.29
Rate for Payer: SELF PAY	$7.29

PRECEPT FACE MASK

Facility

$58.68

Hospital Revenue Code	270
Min. Negotiated Rate	$29.34
Max. Negotiated Rate	$29.34
Rate for Payer: SELF PAY	$29.34

PREGESTIMIL

Facility

$112.34

Hospital Revenue Code	270
Min. Negotiated Rate	$56.17
Max. Negotiated Rate	$56.17
Rate for Payer: SELF PAY	$56.17

Prematurity with major problems

Facility

$51,200.00

Service Code	MSDRG 791
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

Prematurity without major problems

Facility

$51,200.00

Service Code	MSDRG 792
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

PRESSURE EASY CUFF CONTROLLER

Facility

$32.50

Hospital Revenue Code	270
Min. Negotiated Rate	$16.25
Max. Negotiated Rate	$16.25
Rate for Payer: SELF PAY	$16.25

Pressure Infusion Bag 1000ml

Facility

$35.32

Hospital Revenue Code	270
Min. Negotiated Rate	$17.66
Max. Negotiated Rate	$17.66
Rate for Payer: SELF PAY	$17.66

PREVAIL 3XL BRIEF

Facility

$22.72

Hospital Revenue Code	270
Min. Negotiated Rate	$11.36
Max. Negotiated Rate	$11.36
Rate for Payer: SELF PAY	$11.36

PREVAIL 3XL BRIEF WP

Facility

$2.28

Hospital Revenue Code	270
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$1.14
Rate for Payer: SELF PAY	$1.14

Know your out-of-pocket cost for care.

All Charges