Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

TRACH TIE ADULT

Facility

$5.48

Hospital Revenue Code	270
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$2.74
Rate for Payer: SELF PAY	$2.74

TRACH TIE ADULT WP

Facility

$5.48

Hospital Revenue Code	270
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$2.74
Rate for Payer: SELF PAY	$2.74

TRACH TIE BARIATRIC

Facility

$7.94

Hospital Revenue Code	270
Min. Negotiated Rate	$3.97
Max. Negotiated Rate	$3.97
Rate for Payer: SELF PAY	$3.97

TRACH TIE BARIATRIC WP

Facility

$7.94

Hospital Revenue Code	270
Min. Negotiated Rate	$3.97
Max. Negotiated Rate	$3.97
Rate for Payer: SELF PAY	$3.97

TRACH TIE PEDIATRIC

Facility

$4.34

Hospital Revenue Code	270
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$2.17
Rate for Payer: SELF PAY	$2.17

TRACH VENT

Facility

$3.30

Hospital Revenue Code	270
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$1.65
Rate for Payer: SELF PAY	$1.65

TRANSFERRIN

Facility

$48.00

Service Code	CPT 84466
Hospital Revenue Code	300
Min. Negotiated Rate	$24.00
Max. Negotiated Rate	$24.00
Rate for Payer: SELF PAY	$24.00

Transfuse 1 Unit PRBC

Facility

$667.80

Hospital Revenue Code	390
Min. Negotiated Rate	$333.90
Max. Negotiated Rate	$333.90
Rate for Payer: SELF PAY	$333.90

Transfuse 2 Units PRBC

Facility

$375.40

Hospital Revenue Code	390
Min. Negotiated Rate	$187.70
Max. Negotiated Rate	$187.70
Rate for Payer: SELF PAY	$187.70

Transient ischemia without thrombolytic

Facility

$51,200.00

Service Code	MSDRG 69
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

Transurethral procedures with CC

Facility

$60,800.00

Service Code	MSDRG 669
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

Transurethral procedures with MCC

Facility

$60,800.00

Service Code	MSDRG 668
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

Transurethral procedures without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 670
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

Transurethral prostatectomy with CC/MCC

Facility

$76,800.00

Service Code	MSDRG 713
Min. Negotiated Rate	$36,275.71
Max. Negotiated Rate	$40,306.34
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$40,306.34
Rate for Payer: American Health Plans Medicare Advantage	$40,306.34
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$40,306.34
Rate for Payer: CIGNA Medicare Advantage	$40,306.34
Rate for Payer: HealthChoice Utah Medicare Advantage	$40,306.34
Rate for Payer: Humana Medicare Advantage	$40,306.34
Rate for Payer: Medicare	$40,306.34
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$40,306.34
Rate for Payer: MOLINA MEDICARE	$40,306.34
Rate for Payer: Pacific Source Medicare Advantage	$40,306.34
Rate for Payer: Select Health Medicare Advantage	$40,306.34
Rate for Payer: SELF PAY	$38,400.00
Rate for Payer: Tricare West Military	$36,275.71

Transurethral prostatectomy without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 714
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

Trapeze/Day

Facility

$3.50

Hospital Revenue Code	290
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$1.75
Rate for Payer: SELF PAY	$1.75

Traumatic injury with MCC

Facility

$51,200.00

Service Code	MSDRG 913
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

Traumatic injury without MCC

Facility

$51,200.00

Service Code	MSDRG 914
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

Traumatic stupor and coma <1 hour with CC*

Facility

$70,400.00

Service Code	MSDRG 86
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

Traumatic stupor and coma >1 hour with CC

Facility

$70,400.00

Service Code	MSDRG 83
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

Traumatic stupor and coma <1 hour with MCC

Facility

$70,400.00

Service Code	MSDRG 85
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

Traumatic stupor and coma >1 hour with MCC

Facility

$89,600.00

Service Code	MSDRG 82
Min. Negotiated Rate	$41,731.94
Max. Negotiated Rate	$46,368.82
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$46,368.82
Rate for Payer: American Health Plans Medicare Advantage	$46,368.82
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$46,368.82
Rate for Payer: CIGNA Medicare Advantage	$46,368.82
Rate for Payer: HealthChoice Utah Medicare Advantage	$46,368.82
Rate for Payer: Humana Medicare Advantage	$46,368.82
Rate for Payer: Medicare	$46,368.82
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$46,368.82
Rate for Payer: MOLINA MEDICARE	$46,368.82
Rate for Payer: Pacific Source Medicare Advantage	$46,368.82
Rate for Payer: Select Health Medicare Advantage	$46,368.82
Rate for Payer: SELF PAY	$44,800.00
Rate for Payer: Tricare West Military	$41,731.94

Traumatic stupor and coma <1 hour without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 87
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

Traumatic stupor and coma >1 hour without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 84
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

Trauma to the skin, subcutaneous tissue and breast with MCC

Facility

$70,400.00

Service Code	MSDRG 604
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

Know your out-of-pocket cost for care.

All Charges