Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

READY PREP CHG WP

Facility

$3.76

Hospital Revenue Code	270
Min. Negotiated Rate	$1.88
Max. Negotiated Rate	$1.88
Rate for Payer: SELF PAY	$1.88

Rectal resection with CC

Facility

$64,000.00

Service Code	MSDRG 333
Min. Negotiated Rate	$27,594.78
Max. Negotiated Rate	$30,660.87
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$30,660.87
Rate for Payer: American Health Plans Medicare Advantage	$30,660.87
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$30,660.87
Rate for Payer: CIGNA Medicare Advantage	$30,660.87
Rate for Payer: HealthChoice Utah Medicare Advantage	$30,660.87
Rate for Payer: Humana Medicare Advantage	$30,660.87
Rate for Payer: Medicare	$30,660.87
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$30,660.87
Rate for Payer: MOLINA MEDICARE	$30,660.87
Rate for Payer: Pacific Source Medicare Advantage	$30,660.87
Rate for Payer: Select Health Medicare Advantage	$30,660.87
Rate for Payer: SELF PAY	$32,000.00
Rate for Payer: Tricare West Military	$27,594.78

Rectal resection with MCC

Facility

$64,000.00

Service Code	MSDRG 332
Min. Negotiated Rate	$27,594.78
Max. Negotiated Rate	$30,660.87
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$30,660.87
Rate for Payer: American Health Plans Medicare Advantage	$30,660.87
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$30,660.87
Rate for Payer: CIGNA Medicare Advantage	$30,660.87
Rate for Payer: HealthChoice Utah Medicare Advantage	$30,660.87
Rate for Payer: Humana Medicare Advantage	$30,660.87
Rate for Payer: Medicare	$30,660.87
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$30,660.87
Rate for Payer: MOLINA MEDICARE	$30,660.87
Rate for Payer: Pacific Source Medicare Advantage	$30,660.87
Rate for Payer: Select Health Medicare Advantage	$30,660.87
Rate for Payer: SELF PAY	$32,000.00
Rate for Payer: Tricare West Military	$27,594.78

Rectal resection without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 334
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

Red blood cell disorders with MCC

Facility

$86,400.00

Service Code	MSDRG 811
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

Red blood cell disorders without MCC

Facility

$60,800.00

Service Code	MSDRG 812
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

RED DOT ELECTRODE TELEMETRY WP

Facility

$2.30

Hospital Revenue Code	270
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$1.15
Rate for Payer: SELF PAY	$1.15

Reducing Adapter

Facility

$17.82

Hospital Revenue Code	270
Min. Negotiated Rate	$8.91
Max. Negotiated Rate	$8.91
Rate for Payer: SELF PAY	$8.91

ReintegrationTraing 1 unit

Facility

$44.00

Service Code	CPT 97537
Hospital Revenue Code	430
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$22.00
Rate for Payer: SELF PAY	$22.00

REMEDY SKIN REPAIR CREAM

Facility

$6.58

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

REMEDY SKIN REPAIR CREAM WP

Facility

$6.58

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

Renal failure with CC*

Facility

$60,800.00

Service Code	MSDRG 683
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

Renal failure with MCC

Facility

$70,400.00

Service Code	MSDRG 682
Min. Negotiated Rate	$33,634.04
Max. Negotiated Rate	$37,371.15
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$37,371.15
Rate for Payer: American Health Plans Medicare Advantage	$37,371.15
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$37,371.15
Rate for Payer: CIGNA Medicare Advantage	$37,371.15
Rate for Payer: HealthChoice Utah Medicare Advantage	$37,371.15
Rate for Payer: Humana Medicare Advantage	$37,371.15
Rate for Payer: Medicare	$37,371.15
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$37,371.15
Rate for Payer: MOLINA MEDICARE	$37,371.15
Rate for Payer: Pacific Source Medicare Advantage	$37,371.15
Rate for Payer: Select Health Medicare Advantage	$37,371.15
Rate for Payer: SELF PAY	$35,200.00
Rate for Payer: Tricare West Military	$33,634.04

Renal failure without CC/MCC*

Facility

$60,800.00

Service Code	MSDRG 684
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

RENAL FUNCT PANEL

Facility

$8.68

Service Code	CPT 80069
Hospital Revenue Code	300
Min. Negotiated Rate	$4.34
Max. Negotiated Rate	$4.34
Rate for Payer: SELF PAY	$4.34

Respiratory infections and inflammations with CC*

Facility

$57,600.00

Service Code	MSDRG 178
Min. Negotiated Rate	$22,854.26
Max. Negotiated Rate	$25,393.62
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$25,393.62
Rate for Payer: American Health Plans Medicare Advantage	$25,393.62
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$25,393.62
Rate for Payer: CIGNA Medicare Advantage	$25,393.62
Rate for Payer: HealthChoice Utah Medicare Advantage	$25,393.62
Rate for Payer: Humana Medicare Advantage	$25,393.62
Rate for Payer: Medicare	$25,393.62
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$25,393.62
Rate for Payer: MOLINA MEDICARE	$25,393.62
Rate for Payer: Pacific Source Medicare Advantage	$25,393.62
Rate for Payer: Select Health Medicare Advantage	$25,393.62
Rate for Payer: SELF PAY	$28,800.00
Rate for Payer: Tricare West Military	$22,854.26

Respiratory infections and inflammations with MCC

Facility

$67,200.00

Service Code	MSDRG 177
Min. Negotiated Rate	$33,063.08
Max. Negotiated Rate	$36,736.75
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$36,736.75
Rate for Payer: American Health Plans Medicare Advantage	$36,736.75
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$36,736.75
Rate for Payer: CIGNA Medicare Advantage	$36,736.75
Rate for Payer: HealthChoice Utah Medicare Advantage	$36,736.75
Rate for Payer: Humana Medicare Advantage	$36,736.75
Rate for Payer: Medicare	$36,736.75
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$36,736.75
Rate for Payer: MOLINA MEDICARE	$36,736.75
Rate for Payer: Pacific Source Medicare Advantage	$36,736.75
Rate for Payer: Select Health Medicare Advantage	$36,736.75
Rate for Payer: SELF PAY	$33,600.00
Rate for Payer: Tricare West Military	$33,063.08

Respiratory infections and inflammations without CC/MCC*

Facility

$57,600.00

Service Code	MSDRG 179
Min. Negotiated Rate	$22,202.88
Max. Negotiated Rate	$24,669.87
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$24,669.87
Rate for Payer: American Health Plans Medicare Advantage	$24,669.87
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$24,669.87
Rate for Payer: CIGNA Medicare Advantage	$24,669.87
Rate for Payer: HealthChoice Utah Medicare Advantage	$24,669.87
Rate for Payer: Humana Medicare Advantage	$24,669.87
Rate for Payer: Medicare	$24,669.87
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$24,669.87
Rate for Payer: MOLINA MEDICARE	$24,669.87
Rate for Payer: Pacific Source Medicare Advantage	$24,669.87
Rate for Payer: Select Health Medicare Advantage	$24,669.87
Rate for Payer: SELF PAY	$28,800.00
Rate for Payer: Tricare West Military	$22,202.88

Respiratory neoplasms with CC

Facility

$51,200.00

Service Code	MSDRG 181
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

Respiratory neoplasms with MCC

Facility

$70,400.00

Service Code	MSDRG 180
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

Respiratory neoplasms without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 182
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

Respiratory signs and symptoms

Facility

$86,400.00

Service Code	MSDRG 204
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

Respiratory system diagnosis with ventilator support <=96 hours

Facility

$67,200.00

Service Code	MSDRG 208
Min. Negotiated Rate	$42,817.55
Max. Negotiated Rate	$47,575.06
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$47,575.06
Rate for Payer: American Health Plans Medicare Advantage	$47,575.06
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$47,575.06
Rate for Payer: CIGNA Medicare Advantage	$47,575.06
Rate for Payer: HealthChoice Utah Medicare Advantage	$47,575.06
Rate for Payer: Humana Medicare Advantage	$47,575.06
Rate for Payer: Medicare	$47,575.06
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$47,575.06
Rate for Payer: MOLINA MEDICARE	$47,575.06
Rate for Payer: Pacific Source Medicare Advantage	$47,575.06
Rate for Payer: Select Health Medicare Advantage	$47,575.06
Rate for Payer: SELF PAY	$33,600.00
Rate for Payer: Tricare West Military	$42,817.55

Respiratory system diagnosis with ventilator support >96 hours

Facility

$102,400.00

Service Code	MSDRG 207
Min. Negotiated Rate	$77,625.66
Max. Negotiated Rate	$86,250.73
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$86,250.73
Rate for Payer: American Health Plans Medicare Advantage	$86,250.73
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$86,250.73
Rate for Payer: CIGNA Medicare Advantage	$86,250.73
Rate for Payer: HealthChoice Utah Medicare Advantage	$86,250.73
Rate for Payer: Humana Medicare Advantage	$86,250.73
Rate for Payer: Medicare	$86,250.73
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$86,250.73
Rate for Payer: MOLINA MEDICARE	$86,250.73
Rate for Payer: Pacific Source Medicare Advantage	$86,250.73
Rate for Payer: Select Health Medicare Advantage	$86,250.73
Rate for Payer: SELF PAY	$51,200.00
Rate for Payer: Tricare West Military	$77,625.66

RESP PANEL PCR

Facility

$320.77

Hospital Revenue Code	300
Min. Negotiated Rate	$160.38
Max. Negotiated Rate	$160.38
Rate for Payer: SELF PAY	$160.38

Know your out-of-pocket cost for care.

All Charges