Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

SHILEY TRACH UNCUFFED 3.0 PED

Facility

$121.66

Hospital Revenue Code	270
Min. Negotiated Rate	$60.83
Max. Negotiated Rate	$60.83
Rate for Payer: SELF PAY	$60.83

SHILEY TRACH UNCUFFED 4.0 ADUL

Facility

$80.52

Hospital Revenue Code	270
Min. Negotiated Rate	$40.26
Max. Negotiated Rate	$40.26
Rate for Payer: SELF PAY	$40.26

SHILEY TRACH UNCUFFED SIZE 6.0

Facility

$80.52

Hospital Revenue Code	270
Min. Negotiated Rate	$40.26
Max. Negotiated Rate	$40.26
Rate for Payer: SELF PAY	$40.26

Short Arm Splint (15")

Facility

$101.52

Service Code	CPT 29125
Hospital Revenue Code	430
Min. Negotiated Rate	$50.76
Max. Negotiated Rate	$50.76
Rate for Payer: SELF PAY	$50.76

Shoulder, elbow or forearm procedures, except major joint procedures with CC

Facility

$70,400.00

Service Code	MSDRG 511
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

Shoulder, elbow or forearm procedures, except major joint procedures with MCC

Facility

$86,400.00

Service Code	MSDRG 510
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

Shoulder, elbow or forearm procedures, except major joint procedures without CC/MCC

Facility

$64,000.00

Service Code	MSDRG 512
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

Signs and symptoms of musculoskeletal system and connective tissue with MCC

Facility

$112,000.00

Service Code	MSDRG 555
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

Signs and symptoms of musculoskeletal system and connective tissue without MCC

Facility

$51,200.00

Service Code	MSDRG 556
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

Signs and symptoms with MCC

Facility

$60,800.00

Service Code	MSDRG 947
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

Signs and symptoms without MCC

Facility

$51,200.00

Service Code	MSDRG 948
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

Silicone Bulb Evacuators for C

Facility

$136.20

Hospital Revenue Code	270
Min. Negotiated Rate	$68.10
Max. Negotiated Rate	$68.10
Rate for Payer: SELF PAY	$68.10

SILICONE SACRUM FOAM DRESSING

Facility

$11.90

Hospital Revenue Code	270
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$5.95
Rate for Payer: SELF PAY	$5.95

SIMILAC ADVANCE

Facility

$35.86

Hospital Revenue Code	270
Min. Negotiated Rate	$17.93
Max. Negotiated Rate	$17.93
Rate for Payer: SELF PAY	$17.93

SIMILAC ALIMENTUM

Facility

$59.06

Hospital Revenue Code	270
Min. Negotiated Rate	$29.53
Max. Negotiated Rate	$29.53
Rate for Payer: SELF PAY	$29.53

SIMILAC NEOSURE

Facility

$40.74

Hospital Revenue Code	270
Min. Negotiated Rate	$20.37
Max. Negotiated Rate	$20.37
Rate for Payer: SELF PAY	$20.37

SIMILAC TOTAL COMFORT

Facility

$37.26

Hospital Revenue Code	270
Min. Negotiated Rate	$18.63
Max. Negotiated Rate	$18.63
Rate for Payer: SELF PAY	$18.63

Simple pneumonia and pleurisy with CC

Facility

$54,400.00

Service Code	MSDRG 194
Min. Negotiated Rate	$20,811.69
Max. Negotiated Rate	$23,124.10
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$23,124.10
Rate for Payer: American Health Plans Medicare Advantage	$23,124.10
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$23,124.10
Rate for Payer: CIGNA Medicare Advantage	$23,124.10
Rate for Payer: HealthChoice Utah Medicare Advantage	$23,124.10
Rate for Payer: Humana Medicare Advantage	$23,124.10
Rate for Payer: Medicare	$23,124.10
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$23,124.10
Rate for Payer: MOLINA MEDICARE	$23,124.10
Rate for Payer: Pacific Source Medicare Advantage	$23,124.10
Rate for Payer: Select Health Medicare Advantage	$23,124.10
Rate for Payer: SELF PAY	$27,200.00
Rate for Payer: Tricare West Military	$20,811.69

Simple pneumonia and pleurisy with MCC

Facility

$60,800.00

Service Code	MSDRG 193
Min. Negotiated Rate	$31,225.57
Max. Negotiated Rate	$34,695.08
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$34,695.08
Rate for Payer: American Health Plans Medicare Advantage	$34,695.08
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$34,695.08
Rate for Payer: CIGNA Medicare Advantage	$34,695.08
Rate for Payer: HealthChoice Utah Medicare Advantage	$34,695.08
Rate for Payer: Humana Medicare Advantage	$34,695.08
Rate for Payer: Medicare	$34,695.08
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$34,695.08
Rate for Payer: MOLINA MEDICARE	$34,695.08
Rate for Payer: Pacific Source Medicare Advantage	$34,695.08
Rate for Payer: Select Health Medicare Advantage	$34,695.08
Rate for Payer: SELF PAY	$30,400.00
Rate for Payer: Tricare West Military	$31,225.57

Simple pneumonia and pleurisy without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 195
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

Single Lumen Midline Insertion

Facility

$750.00

Hospital Revenue Code	320
Min. Negotiated Rate	$375.00
Max. Negotiated Rate	$375.00
Rate for Payer: SELF PAY	$375.00

Sinus and mastoid procedures with CC/MCC

Facility

$102,400.00

Service Code	MSDRG 135
Min. Negotiated Rate	$60,834.78
Max. Negotiated Rate	$67,594.20
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$67,594.20
Rate for Payer: American Health Plans Medicare Advantage	$67,594.20
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$67,594.20
Rate for Payer: CIGNA Medicare Advantage	$67,594.20
Rate for Payer: HealthChoice Utah Medicare Advantage	$67,594.20
Rate for Payer: Humana Medicare Advantage	$67,594.20
Rate for Payer: Medicare	$67,594.20
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$67,594.20
Rate for Payer: MOLINA MEDICARE	$67,594.20
Rate for Payer: Pacific Source Medicare Advantage	$67,594.20
Rate for Payer: Select Health Medicare Advantage	$67,594.20
Rate for Payer: SELF PAY	$51,200.00
Rate for Payer: Tricare West Military	$60,834.78

Sinus and mastoid procedures without CC/MCC

Facility

$86,400.00

Service Code	MSDRG 136
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

SINUS CULTURE

Facility

$16.00

Service Code	CPT 87070
Hospital Revenue Code	300
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$8.00
Rate for Payer: SELF PAY	$8.00

SKIN BARRIER ARC

Facility

$1.36

Hospital Revenue Code	270
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.68
Rate for Payer: SELF PAY	$0.68

Know your out-of-pocket cost for care.

All Charges