Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

Spinal disorders and injuries without CC/MCC*

Facility

$124,800.00

Service Code	MSDRG 53
Min. Negotiated Rate	$42,684.87
Max. Negotiated Rate	$47,427.63
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$47,427.63
Rate for Payer: American Health Plans Medicare Advantage	$47,427.63
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$47,427.63
Rate for Payer: CIGNA Medicare Advantage	$47,427.63
Rate for Payer: HealthChoice Utah Medicare Advantage	$47,427.63
Rate for Payer: Humana Medicare Advantage	$47,427.63
Rate for Payer: Medicare	$47,427.63
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$47,427.63
Rate for Payer: MOLINA MEDICARE	$47,427.63
Rate for Payer: Pacific Source Medicare Advantage	$47,427.63
Rate for Payer: Select Health Medicare Advantage	$47,427.63
Rate for Payer: SELF PAY	$62,400.00
Rate for Payer: Tricare West Military	$42,684.87

Spinal fusion except cervical with MCC

Facility

$67,200.00

Service Code	MSDRG 459
Min. Negotiated Rate	$35,266.48
Max. Negotiated Rate	$39,184.98
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$39,184.98
Rate for Payer: American Health Plans Medicare Advantage	$39,184.98
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$39,184.98
Rate for Payer: CIGNA Medicare Advantage	$39,184.98
Rate for Payer: HealthChoice Utah Medicare Advantage	$39,184.98
Rate for Payer: Humana Medicare Advantage	$39,184.98
Rate for Payer: Medicare	$39,184.98
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$39,184.98
Rate for Payer: MOLINA MEDICARE	$39,184.98
Rate for Payer: Pacific Source Medicare Advantage	$39,184.98
Rate for Payer: Select Health Medicare Advantage	$39,184.98
Rate for Payer: SELF PAY	$33,600.00
Rate for Payer: Tricare West Military	$35,266.48

Spinal fusion except cervical without MCC

Facility

$70,400.00

Service Code	MSDRG 460
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

Spinal fusion except cervical with spinal curvature, malignancy, infection or extensive fusions with CC

Facility

$70,400.00

Service Code	MSDRG 457
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

Spinal fusion except cervical with spinal curvature, malignancy, infection or extensive fusions with MCC

Facility

$112,000.00

Service Code	MSDRG 456
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

Spinal fusion except cervical with spinal curvature, malignancy, infection or extensive fusions without CC/MCC

Facility

$64,000.00

Service Code	MSDRG 458
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

Spinal procedures with CC or spinal neurostimulators

Facility

$112,000.00

Service Code	MSDRG 29
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

Spinal procedures with MCC

Facility

$112,000.00

Service Code	MSDRG 28
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

Spinal procedures without CC/MCC

Facility

$112,000.00

Service Code	MSDRG 30
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

Splenic procedures with CC

Facility

$99,200.00

Service Code	MSDRG 800
Min. Negotiated Rate	$59,897.93
Max. Negotiated Rate	$66,553.26
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$66,553.26
Rate for Payer: American Health Plans Medicare Advantage	$66,553.26
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$66,553.26
Rate for Payer: CIGNA Medicare Advantage	$66,553.26
Rate for Payer: HealthChoice Utah Medicare Advantage	$66,553.26
Rate for Payer: Humana Medicare Advantage	$66,553.26
Rate for Payer: Medicare	$66,553.26
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$66,553.26
Rate for Payer: MOLINA MEDICARE	$66,553.26
Rate for Payer: Pacific Source Medicare Advantage	$66,553.26
Rate for Payer: Select Health Medicare Advantage	$66,553.26
Rate for Payer: SELF PAY	$49,600.00
Rate for Payer: Tricare West Military	$59,897.93

Splenic procedures with MCC

Facility

$99,200.00

Service Code	MSDRG 799
Min. Negotiated Rate	$59,897.93
Max. Negotiated Rate	$66,553.26
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$66,553.26
Rate for Payer: American Health Plans Medicare Advantage	$66,553.26
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$66,553.26
Rate for Payer: CIGNA Medicare Advantage	$66,553.26
Rate for Payer: HealthChoice Utah Medicare Advantage	$66,553.26
Rate for Payer: Humana Medicare Advantage	$66,553.26
Rate for Payer: Medicare	$66,553.26
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$66,553.26
Rate for Payer: MOLINA MEDICARE	$66,553.26
Rate for Payer: Pacific Source Medicare Advantage	$66,553.26
Rate for Payer: Select Health Medicare Advantage	$66,553.26
Rate for Payer: SELF PAY	$49,600.00
Rate for Payer: Tricare West Military	$59,897.93

Splenic procedures without CC/MCC

Facility

$99,200.00

Service Code	MSDRG 801
Min. Negotiated Rate	$59,897.93
Max. Negotiated Rate	$66,553.26
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$66,553.26
Rate for Payer: American Health Plans Medicare Advantage	$66,553.26
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$66,553.26
Rate for Payer: CIGNA Medicare Advantage	$66,553.26
Rate for Payer: HealthChoice Utah Medicare Advantage	$66,553.26
Rate for Payer: Humana Medicare Advantage	$66,553.26
Rate for Payer: Medicare	$66,553.26
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$66,553.26
Rate for Payer: MOLINA MEDICARE	$66,553.26
Rate for Payer: Pacific Source Medicare Advantage	$66,553.26
Rate for Payer: Select Health Medicare Advantage	$66,553.26
Rate for Payer: SELF PAY	$49,600.00
Rate for Payer: Tricare West Military	$59,897.93

Sprains, strains, and dislocations of hip, pelvis and thigh with CC/MCC

Facility

$70,400.00

Service Code	MSDRG 537
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

Sprains, strains, and dislocations of hip, pelvis and thigh without CC/MCC

Facility

$64,000.00

Service Code	MSDRG 538
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

SPUTUM CULTURE

Facility

$216.80

Service Code	CPT 87070
Hospital Revenue Code	300
Min. Negotiated Rate	$108.40
Max. Negotiated Rate	$108.40
Rate for Payer: SELF PAY	$108.40

ST-1 Unit; Mngd Care

Facility

$38.66

Service Code	CPT 92900
Hospital Revenue Code	440
Min. Negotiated Rate	$19.33
Max. Negotiated Rate	$19.33
Rate for Payer: SELF PAY	$19.33

STAPLE REMOVER

Facility

$3.70

Hospital Revenue Code	270
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$1.85
Rate for Payer: SELF PAY	$1.85

STAPLE REMOVER WP

Facility

$3.70

Hospital Revenue Code	270
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$1.85
Rate for Payer: SELF PAY	$1.85

STERILE COTTON BALLS

Facility

$0.78

Hospital Revenue Code	270
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.39
Rate for Payer: SELF PAY	$0.39

STERI STRIP 1/2X4

Facility

$1.48

Hospital Revenue Code	270
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$0.74
Rate for Payer: SELF PAY	$0.74

STERI STRIP 1/2 X 4 WP

Facility

$1.48

Hospital Revenue Code	270
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$0.74
Rate for Payer: SELF PAY	$0.74

STERI STRIP 1/4 X 3

Facility

$1.82

Hospital Revenue Code	270
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$0.91
Rate for Payer: SELF PAY	$0.91

STERI STRIP 1/4 X 3 WP

Facility

$1.82

Hospital Revenue Code	270
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$0.91
Rate for Payer: SELF PAY	$0.91

STERI STRIP 1/8X3

Facility

$1.98

Hospital Revenue Code	270
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$0.99
Rate for Payer: SELF PAY	$0.99

STERI STRIP 1/8 X 3 WP

Facility

$1.98

Hospital Revenue Code	270
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$0.99
Rate for Payer: SELF PAY	$0.99

Know your out-of-pocket cost for care.

All Charges