Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

SKIN BARRIER ARC WP

Facility

$1.36

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

Skin debridement with CC

Facility

$89,600.00

Service Code	MSDRG 571
Min. Negotiated Rate	$38,056.91
Max. Negotiated Rate	$42,285.46
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$42,285.46
Rate for Payer: American Health Plans Medicare Advantage	$42,285.46
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$42,285.46
Rate for Payer: CIGNA Medicare Advantage	$42,285.46
Rate for Payer: HealthChoice Utah Medicare Advantage	$42,285.46
Rate for Payer: Humana Medicare Advantage	$42,285.46
Rate for Payer: Medicare	$42,285.46
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$42,285.46
Rate for Payer: MOLINA MEDICARE	$42,285.46
Rate for Payer: Pacific Source Medicare Advantage	$42,285.46
Rate for Payer: Select Health Medicare Advantage	$42,285.46
Rate for Payer: SELF PAY	$44,800.00
Rate for Payer: Tricare West Military	$38,056.91

Skin debridement with MCC

Facility

$105,600.00

Service Code	MSDRG 570
Min. Negotiated Rate	$52,885.65
Max. Negotiated Rate	$58,761.83
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$58,761.83
Rate for Payer: American Health Plans Medicare Advantage	$58,761.83
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$58,761.83
Rate for Payer: CIGNA Medicare Advantage	$58,761.83
Rate for Payer: HealthChoice Utah Medicare Advantage	$58,761.83
Rate for Payer: Humana Medicare Advantage	$58,761.83
Rate for Payer: Medicare	$58,761.83
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$58,761.83
Rate for Payer: MOLINA MEDICARE	$58,761.83
Rate for Payer: Pacific Source Medicare Advantage	$58,761.83
Rate for Payer: Select Health Medicare Advantage	$58,761.83
Rate for Payer: SELF PAY	$52,800.00
Rate for Payer: Tricare West Military	$52,885.65

Skin debridement without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 572
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

Skin Fold Management

Facility

$101.28

Hospital Revenue Code	270
Min. Negotiated Rate	$50.64
Max. Negotiated Rate	$50.64
Rate for Payer: SELF PAY	$50.64

Skin graft except for skin ulcer or cellulitis with CC

Facility

$112,000.00

Service Code	MSDRG 577
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

Skin graft except for skin ulcer or cellulitis with MCC*

Facility

$112,000.00

Service Code	MSDRG 576
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

Skin graft except for skin ulcer or cellulitis without CC/MCC

Facility

$112,000.00

Service Code	MSDRG 578
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

Skin graft for skin ulcer or cellulitis with CC*

Facility

$115,200.00

Service Code	MSDRG 574
Min. Negotiated Rate	$62,459.18
Max. Negotiated Rate	$69,399.09
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$69,399.09
Rate for Payer: American Health Plans Medicare Advantage	$69,399.09
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$69,399.09
Rate for Payer: CIGNA Medicare Advantage	$69,399.09
Rate for Payer: HealthChoice Utah Medicare Advantage	$69,399.09
Rate for Payer: Humana Medicare Advantage	$69,399.09
Rate for Payer: Medicare	$69,399.09
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$69,399.09
Rate for Payer: MOLINA MEDICARE	$69,399.09
Rate for Payer: Pacific Source Medicare Advantage	$69,399.09
Rate for Payer: Select Health Medicare Advantage	$69,399.09
Rate for Payer: SELF PAY	$57,600.00
Rate for Payer: Tricare West Military	$62,459.18

Skin graft for skin ulcer or cellulitis with MCC*

Facility

$115,200.00

Service Code	MSDRG 573
Min. Negotiated Rate	$62,459.18
Max. Negotiated Rate	$69,399.09
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$69,399.09
Rate for Payer: American Health Plans Medicare Advantage	$69,399.09
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$69,399.09
Rate for Payer: CIGNA Medicare Advantage	$69,399.09
Rate for Payer: HealthChoice Utah Medicare Advantage	$69,399.09
Rate for Payer: Humana Medicare Advantage	$69,399.09
Rate for Payer: Medicare	$69,399.09
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$69,399.09
Rate for Payer: MOLINA MEDICARE	$69,399.09
Rate for Payer: Pacific Source Medicare Advantage	$69,399.09
Rate for Payer: Select Health Medicare Advantage	$69,399.09
Rate for Payer: SELF PAY	$57,600.00
Rate for Payer: Tricare West Military	$62,459.18

Skin graft for skin ulcer or cellulitis without CC/MCC

Facility

$89,600.00

Service Code	MSDRG 575
Min. Negotiated Rate	$40,674.46
Max. Negotiated Rate	$45,193.85
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$45,193.85
Rate for Payer: American Health Plans Medicare Advantage	$45,193.85
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$45,193.85
Rate for Payer: CIGNA Medicare Advantage	$45,193.85
Rate for Payer: HealthChoice Utah Medicare Advantage	$45,193.85
Rate for Payer: Humana Medicare Advantage	$45,193.85
Rate for Payer: Medicare	$45,193.85
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$45,193.85
Rate for Payer: MOLINA MEDICARE	$45,193.85
Rate for Payer: Pacific Source Medicare Advantage	$45,193.85
Rate for Payer: Select Health Medicare Advantage	$45,193.85
Rate for Payer: SELF PAY	$44,800.00
Rate for Payer: Tricare West Military	$40,674.46

Skin grafts and wound debridement for endocrine, nutritional and metabolic disorders with CC

Facility

$89,600.00

Service Code	MSDRG 623
Min. Negotiated Rate	$40,807.15
Max. Negotiated Rate	$45,341.28
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$45,341.28
Rate for Payer: American Health Plans Medicare Advantage	$45,341.28
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$45,341.28
Rate for Payer: CIGNA Medicare Advantage	$45,341.28
Rate for Payer: HealthChoice Utah Medicare Advantage	$45,341.28
Rate for Payer: Humana Medicare Advantage	$45,341.28
Rate for Payer: Medicare	$45,341.28
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$45,341.28
Rate for Payer: MOLINA MEDICARE	$45,341.28
Rate for Payer: Pacific Source Medicare Advantage	$45,341.28
Rate for Payer: Select Health Medicare Advantage	$45,341.28
Rate for Payer: SELF PAY	$44,800.00
Rate for Payer: Tricare West Military	$40,807.15

Skin grafts and wound debridement for endocrine, nutritional and metabolic disorders with MCC

Facility

$108,800.00

Service Code	MSDRG 622
Min. Negotiated Rate	$56,966.76
Max. Negotiated Rate	$63,296.40
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$63,296.40
Rate for Payer: American Health Plans Medicare Advantage	$63,296.40
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$63,296.40
Rate for Payer: CIGNA Medicare Advantage	$63,296.40
Rate for Payer: HealthChoice Utah Medicare Advantage	$63,296.40
Rate for Payer: Humana Medicare Advantage	$63,296.40
Rate for Payer: Medicare	$63,296.40
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$63,296.40
Rate for Payer: MOLINA MEDICARE	$63,296.40
Rate for Payer: Pacific Source Medicare Advantage	$63,296.40
Rate for Payer: Select Health Medicare Advantage	$63,296.40
Rate for Payer: SELF PAY	$54,400.00
Rate for Payer: Tricare West Military	$56,966.76

Skin grafts and wound debridement for endocrine, nutritional and metabolic disorders without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 624
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

Skin grafts for injuries with CC/MCC

Facility

$86,400.00

Service Code	MSDRG 904
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

Skin grafts for injuries without CC/MCC

Facility

$86,400.00

Service Code	MSDRG 905
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

SKIN PREP WIPE

Facility

$0.14

Hospital Revenue Code	270
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.07
Rate for Payer: SELF PAY	$0.07

SKIN PREP WIPE WP

Facility

$0.14

Hospital Revenue Code	270
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.07
Rate for Payer: SELF PAY	$0.07

Skin ulcers with CC*

Facility

$70,400.00

Service Code	MSDRG 593
Min. Negotiated Rate	$27,598.81
Max. Negotiated Rate	$30,665.34
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$30,665.34
Rate for Payer: American Health Plans Medicare Advantage	$30,665.34
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$30,665.34
Rate for Payer: CIGNA Medicare Advantage	$30,665.34
Rate for Payer: HealthChoice Utah Medicare Advantage	$30,665.34
Rate for Payer: Humana Medicare Advantage	$30,665.34
Rate for Payer: Medicare	$30,665.34
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$30,665.34
Rate for Payer: MOLINA MEDICARE	$30,665.34
Rate for Payer: Pacific Source Medicare Advantage	$30,665.34
Rate for Payer: Select Health Medicare Advantage	$30,665.34
Rate for Payer: SELF PAY	$35,200.00
Rate for Payer: Tricare West Military	$27,598.81

Skin ulcers with MCC

Facility

$80,000.00

Service Code	MSDRG 592
Min. Negotiated Rate	$37,691.03
Max. Negotiated Rate	$41,878.92
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$41,878.92
Rate for Payer: American Health Plans Medicare Advantage	$41,878.92
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$41,878.92
Rate for Payer: CIGNA Medicare Advantage	$41,878.92
Rate for Payer: HealthChoice Utah Medicare Advantage	$41,878.92
Rate for Payer: Humana Medicare Advantage	$41,878.92
Rate for Payer: Medicare	$41,878.92
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$41,878.92
Rate for Payer: MOLINA MEDICARE	$41,878.92
Rate for Payer: Pacific Source Medicare Advantage	$41,878.92
Rate for Payer: Select Health Medicare Advantage	$41,878.92
Rate for Payer: SELF PAY	$40,000.00
Rate for Payer: Tricare West Military	$37,691.03

Skin ulcers without CC/MCC*

Facility

$70,400.00

Service Code	MSDRG 594
Min. Negotiated Rate	$26,497.11
Max. Negotiated Rate	$29,441.23
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$29,441.23
Rate for Payer: American Health Plans Medicare Advantage	$29,441.23
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$29,441.23
Rate for Payer: CIGNA Medicare Advantage	$29,441.23
Rate for Payer: HealthChoice Utah Medicare Advantage	$29,441.23
Rate for Payer: Humana Medicare Advantage	$29,441.23
Rate for Payer: Medicare	$29,441.23
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$29,441.23
Rate for Payer: MOLINA MEDICARE	$29,441.23
Rate for Payer: Pacific Source Medicare Advantage	$29,441.23
Rate for Payer: Select Health Medicare Advantage	$29,441.23
Rate for Payer: SELF PAY	$35,200.00
Rate for Payer: Tricare West Military	$26,497.11

SK Machine Portable

Facility

$18.50

Hospital Revenue Code	290
Min. Negotiated Rate	$9.25
Max. Negotiated Rate	$9.25
Rate for Payer: SELF PAY	$9.25

SLIPPER MEDIUM

Facility

$1.28

Hospital Revenue Code	270
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.64
Rate for Payer: SELF PAY	$0.64

SLIPPER NONSKID 2XL

Facility

$1.34

Hospital Revenue Code	270
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.67
Rate for Payer: SELF PAY	$0.67

SLIPPER NONSKID 2XL WP

Facility

$1.28

Hospital Revenue Code	270
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.64
Rate for Payer: SELF PAY	$0.64

Know your out-of-pocket cost for care.

All Charges