Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

SENSURA MIO KIDS 0 - 1 3/8

Facility

$2.74

Hospital Revenue Code	270
Min. Negotiated Rate	$1.37
Max. Negotiated Rate	$1.37
Rate for Payer: SELF PAY	$1.37

Septic arthritis with CC

Facility

$70,400.00

Service Code	MSDRG 549
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

Septic arthritis with MCC

Facility

$73,600.00

Service Code	MSDRG 548
Min. Negotiated Rate	$33,593.82
Max. Negotiated Rate	$37,326.47
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$37,326.47
Rate for Payer: American Health Plans Medicare Advantage	$37,326.47
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$37,326.47
Rate for Payer: CIGNA Medicare Advantage	$37,326.47
Rate for Payer: HealthChoice Utah Medicare Advantage	$37,326.47
Rate for Payer: Humana Medicare Advantage	$37,326.47
Rate for Payer: Medicare	$37,326.47
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$37,326.47
Rate for Payer: MOLINA MEDICARE	$37,326.47
Rate for Payer: Pacific Source Medicare Advantage	$37,326.47
Rate for Payer: Select Health Medicare Advantage	$37,326.47
Rate for Payer: SELF PAY	$36,800.00
Rate for Payer: Tricare West Military	$33,593.82

Septic arthritis without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 550
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

Septicemia or severe sepsis with MV >96 hours

Facility

$92,800.00

Service Code	MSDRG 870
Min. Negotiated Rate	$82,064.63
Max. Negotiated Rate	$91,182.92
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$91,182.92
Rate for Payer: American Health Plans Medicare Advantage	$91,182.92
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$91,182.92
Rate for Payer: CIGNA Medicare Advantage	$91,182.92
Rate for Payer: HealthChoice Utah Medicare Advantage	$91,182.92
Rate for Payer: Humana Medicare Advantage	$91,182.92
Rate for Payer: Medicare	$91,182.92
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$91,182.92
Rate for Payer: MOLINA MEDICARE	$91,182.92
Rate for Payer: Pacific Source Medicare Advantage	$91,182.92
Rate for Payer: Select Health Medicare Advantage	$91,182.92
Rate for Payer: SELF PAY	$46,400.00
Rate for Payer: Tricare West Military	$82,064.63

Septicemia or severe sepsis without MV >96 hours with MCC

Facility

$70,400.00

Service Code	MSDRG 871
Min. Negotiated Rate	$36,677.78
Max. Negotiated Rate	$40,753.09
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$40,753.09
Rate for Payer: American Health Plans Medicare Advantage	$40,753.09
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$40,753.09
Rate for Payer: CIGNA Medicare Advantage	$40,753.09
Rate for Payer: HealthChoice Utah Medicare Advantage	$40,753.09
Rate for Payer: Humana Medicare Advantage	$40,753.09
Rate for Payer: Medicare	$40,753.09
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$40,753.09
Rate for Payer: MOLINA MEDICARE	$40,753.09
Rate for Payer: Pacific Source Medicare Advantage	$40,753.09
Rate for Payer: Select Health Medicare Advantage	$40,753.09
Rate for Payer: SELF PAY	$35,200.00
Rate for Payer: Tricare West Military	$36,677.78

Septicemia or severe sepsis without MV >96 hours without MCC

Facility

$60,800.00

Service Code	MSDRG 872
Min. Negotiated Rate	$25,548.19
Max. Negotiated Rate	$28,386.88
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$28,386.88
Rate for Payer: American Health Plans Medicare Advantage	$28,386.88
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$28,386.88
Rate for Payer: CIGNA Medicare Advantage	$28,386.88
Rate for Payer: HealthChoice Utah Medicare Advantage	$28,386.88
Rate for Payer: Humana Medicare Advantage	$28,386.88
Rate for Payer: Medicare	$28,386.88
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$28,386.88
Rate for Payer: MOLINA MEDICARE	$28,386.88
Rate for Payer: Pacific Source Medicare Advantage	$28,386.88
Rate for Payer: Select Health Medicare Advantage	$28,386.88
Rate for Payer: SELF PAY	$30,400.00
Rate for Payer: Tricare West Military	$25,548.19

Serum B 12

Facility

$190.00

Service Code	CPT 82607
Hospital Revenue Code	300
Min. Negotiated Rate	$95.00
Max. Negotiated Rate	$95.00
Rate for Payer: SELF PAY	$95.00

SERUM FE

Facility

$6.47

Service Code	CPT 83540
Hospital Revenue Code	300
Min. Negotiated Rate	$3.23
Max. Negotiated Rate	$3.23
Rate for Payer: SELF PAY	$3.23

Serum K

Facility

$4.76

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

SERVO DUO GUARD

Facility

$20.30

Hospital Revenue Code	270
Min. Negotiated Rate	$10.15
Max. Negotiated Rate	$10.15
Rate for Payer: SELF PAY	$10.15

SGOT

Facility

$5.18

Service Code	CPT 84450
Hospital Revenue Code	300
Min. Negotiated Rate	$2.59
Max. Negotiated Rate	$2.59
Rate for Payer: SELF PAY	$2.59

SHAMPOO 8oz NO RINSE

Facility

$1.72

Hospital Revenue Code	270
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$0.86
Rate for Payer: SELF PAY	$0.86

SHAMPOO 8oz NO RINSE WP

Facility

$1.72

Hospital Revenue Code	270
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$0.86
Rate for Payer: SELF PAY	$0.86

SHAMPOO BABY TEARLESS 4oz

Facility

$0.90

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

SHAMPOO BABY TEARLESS 4oz 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

SHAMPOO BODY WASH

Facility

$2.76

Hospital Revenue Code	270
Min. Negotiated Rate	$1.38
Max. Negotiated Rate	$1.38
Rate for Payer: SELF PAY	$1.38

SHAMPOO BODY WASH WP

Facility

$2.76

Hospital Revenue Code	270
Min. Negotiated Rate	$1.38
Max. Negotiated Rate	$1.38
Rate for Payer: SELF PAY	$1.38

SHAMPOO CAP

Facility

$5.34

Hospital Revenue Code	270
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$2.67
Rate for Payer: SELF PAY	$2.67

SHAVING CREAM 11oz

Facility

$1.94

Hospital Revenue Code	270
Min. Negotiated Rate	$0.97
Max. Negotiated Rate	$0.97
Rate for Payer: SELF PAY	$0.97

SHAVING CREAM 11oz WP

Facility

$1.94

Hospital Revenue Code	270
Min. Negotiated Rate	$0.97
Max. Negotiated Rate	$0.97
Rate for Payer: SELF PAY	$0.97

SHIGTOX TOXIN

Facility

$79.00

Service Code	CPT 87406
Hospital Revenue Code	300
Min. Negotiated Rate	$39.50
Max. Negotiated Rate	$39.50
Rate for Payer: SELF PAY	$39.50

SHILEY CUFFED TRACH 5.0 ADULT

Facility

$195.90

Hospital Revenue Code	270
Min. Negotiated Rate	$97.95
Max. Negotiated Rate	$97.95
Rate for Payer: SELF PAY	$97.95

SHILEY TRACH CUFFED 8.0

Facility

$106.26

Hospital Revenue Code	270
Min. Negotiated Rate	$53.13
Max. Negotiated Rate	$53.13
Rate for Payer: SELF PAY	$53.13

SHILEY TRACH CUFFED 8.0 WP

Facility

$106.26

Hospital Revenue Code	270
Min. Negotiated Rate	$53.13
Max. Negotiated Rate	$53.13
Rate for Payer: SELF PAY	$53.13

Know your out-of-pocket cost for care.

All Charges