Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

PRIMARY IV ADMINISTRATION SET,

Facility

$13.58

Hospital Revenue Code	270
Min. Negotiated Rate	$6.79
Max. Negotiated Rate	$6.79
Rate for Payer: SELF PAY	$6.79

PROBE STICKER

Facility

$0.90

Hospital Revenue Code	270
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: SELF PAY	$0.45

PROBE STICKER WP

Facility

$0.90

Hospital Revenue Code	270
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: SELF PAY	$0.45

PROFLOW ADULT CANNULA

Facility

$8.64

Hospital Revenue Code	270
Min. Negotiated Rate	$4.32
Max. Negotiated Rate	$4.32
Rate for Payer: SELF PAY	$4.32

PROMOTE W/FIBER

Facility

$3.62

Hospital Revenue Code	270
Min. Negotiated Rate	$1.81
Max. Negotiated Rate	$1.81
Rate for Payer: SELF PAY	$1.81

Promote w/ fiber 8oz

Facility

$1.18

Hospital Revenue Code	270
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.59
Rate for Payer: SELF PAY	$0.59

PROMOTE W/FIBER WP

Facility

$3.62

Hospital Revenue Code	270
Min. Negotiated Rate	$1.81
Max. Negotiated Rate	$1.81
Rate for Payer: SELF PAY	$1.81

Prostatectomy with CC

Facility

$60,800.00

Service Code	MSDRG 666
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

Prostatectomy with MCC

Facility

$112,000.00

Service Code	MSDRG 665
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

Prostatectomy without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 667
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

PROSTATE SPECIFIC AG

Facility

$53.00

Service Code	CPT 84153
Hospital Revenue Code	300
Min. Negotiated Rate	$26.50
Max. Negotiated Rate	$26.50
Rate for Payer: SELF PAY	$26.50

PROSTATE SPECIFIC ANTIGEN

Facility

$53.00

Service Code	CPT 84153
Hospital Revenue Code	300
Min. Negotiated Rate	$26.50
Max. Negotiated Rate	$26.50
Rate for Payer: SELF PAY	$26.50

PROTEIN AND CREATININE RANDOM

Facility

$49.00

Service Code	CPT 82570
Hospital Revenue Code	300
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$24.50
Rate for Payer: SELF PAY	$24.50

PROVOX HME

Facility

$8.58

Hospital Revenue Code	270
Min. Negotiated Rate	$4.29
Max. Negotiated Rate	$4.29
Rate for Payer: SELF PAY	$4.29

PT Evaluation

Facility

$111.00

Service Code	CPT 97001
Hospital Revenue Code	420
Min. Negotiated Rate	$55.50
Max. Negotiated Rate	$55.50
Rate for Payer: SELF PAY	$55.50

PT (PROTIME) w/ INR

Facility

$4.29

Service Code	CPT 85610
Hospital Revenue Code	300
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$2.15
Rate for Payer: SELF PAY	$2.15

P T Re-eval

Facility

$61.00

Service Code	CPT 97002
Hospital Revenue Code	420
Min. Negotiated Rate	$30.50
Max. Negotiated Rate	$30.50
Rate for Payer: SELF PAY	$30.50

PT Re Evaluation

Facility

$61.00

Service Code	CPT 97164
Hospital Revenue Code	420
Min. Negotiated Rate	$30.50
Max. Negotiated Rate	$30.50
Rate for Payer: SELF PAY	$30.50

PTT

Facility

$29.00

Service Code	CPT 85730
Hospital Revenue Code	300
Min. Negotiated Rate	$14.50
Max. Negotiated Rate	$14.50
Rate for Payer: SELF PAY	$14.50

PULLUP BRIEF LARGE

Facility

$15.22

Hospital Revenue Code	270
Min. Negotiated Rate	$7.61
Max. Negotiated Rate	$7.61
Rate for Payer: SELF PAY	$7.61

PULLUP BRIEF LARGE WP

Facility

$0.84

Hospital Revenue Code	270
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.42
Rate for Payer: SELF PAY	$0.42

PULLUP BRIEF MED

Facility

$16.64

Hospital Revenue Code	270
Min. Negotiated Rate	$8.32
Max. Negotiated Rate	$8.32
Rate for Payer: SELF PAY	$8.32

PULLUP BRIEF MED WP

Facility

$1.04

Hospital Revenue Code	270
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.52
Rate for Payer: SELF PAY	$0.52

PULLUP BRIEF XL

Facility

$15.58

Hospital Revenue Code	270
Min. Negotiated Rate	$7.79
Max. Negotiated Rate	$7.79
Rate for Payer: SELF PAY	$7.79

PULLUP BRIEF XL WP

Facility

$1.12

Hospital Revenue Code	270
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.56
Rate for Payer: SELF PAY	$0.56

Know your out-of-pocket cost for care.

All Charges