Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

TV REMOTE

Facility

$16.00

Hospital Revenue Code	270
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$8.00
Rate for Payer: SELF PAY	$8.00

Type and Cross for Blood Transfusion

Facility

$360.96

Hospital Revenue Code	300
Min. Negotiated Rate	$180.48
Max. Negotiated Rate	$180.48
Rate for Payer: SELF PAY	$180.48

Ultrasound (1 unit)

Facility

$19.00

Service Code	CPT 97035
Hospital Revenue Code	420
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$9.50
Rate for Payer: SELF PAY	$9.50

Ultrasound 1 unit

Facility

$19.00

Service Code	CPT 97035
Hospital Revenue Code	430
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$9.50
Rate for Payer: SELF PAY	$9.50

Ultrasound accelerated and other thrombolysis of peripheral vascular structures with MCC

Facility

$96,000.00

Service Code	MSDRG 278
Min. Negotiated Rate	$48,792.46
Max. Negotiated Rate	$54,213.85
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$54,213.85
Rate for Payer: American Health Plans Medicare Advantage	$54,213.85
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$54,213.85
Rate for Payer: CIGNA Medicare Advantage	$54,213.85
Rate for Payer: HealthChoice Utah Medicare Advantage	$54,213.85
Rate for Payer: Humana Medicare Advantage	$54,213.85
Rate for Payer: Medicare	$54,213.85
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$54,213.85
Rate for Payer: MOLINA MEDICARE	$54,213.85
Rate for Payer: Pacific Source Medicare Advantage	$54,213.85
Rate for Payer: Select Health Medicare Advantage	$54,213.85
Rate for Payer: SELF PAY	$48,000.00
Rate for Payer: Tricare West Military	$48,792.46

Ultrasound accelerated and other thrombolysis of peripheral vascular structures without MCC

Facility

$96,000.00

Service Code	MSDRG 279
Min. Negotiated Rate	$48,792.46
Max. Negotiated Rate	$54,213.85
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$54,213.85
Rate for Payer: American Health Plans Medicare Advantage	$54,213.85
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$54,213.85
Rate for Payer: CIGNA Medicare Advantage	$54,213.85
Rate for Payer: HealthChoice Utah Medicare Advantage	$54,213.85
Rate for Payer: Humana Medicare Advantage	$54,213.85
Rate for Payer: Medicare	$54,213.85
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$54,213.85
Rate for Payer: MOLINA MEDICARE	$54,213.85
Rate for Payer: Pacific Source Medicare Advantage	$54,213.85
Rate for Payer: Select Health Medicare Advantage	$54,213.85
Rate for Payer: SELF PAY	$48,000.00
Rate for Payer: Tricare West Military	$48,792.46

Ultrasound accelerated and other thrombolysis with principal diagnosis pulmonary embolism

Facility

$86,400.00

Service Code	MSDRG 173
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

Uncomplicated peptic ulcer with MCC

Facility

$60,800.00

Service Code	MSDRG 383
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

Uncomplicated peptic ulcer without MCC

Facility

$51,200.00

Service Code	MSDRG 384
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

UNIVERSAL FIRM CERVICAL COLLAR

Facility

$5.28

Hospital Revenue Code	270
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$2.64
Rate for Payer: SELF PAY	$2.64

Un-Self Care/Home Mgmt 1 unit

Facility

$34.12

Service Code	CPT 97535
Hospital Revenue Code	430
Min. Negotiated Rate	$17.06
Max. Negotiated Rate	$17.06
Rate for Payer: SELF PAY	$17.06

Upper limb and toe amputation for circulatory system disorders with CC

Facility

$70,400.00

Service Code	MSDRG 256
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

Upper limb and toe amputation for circulatory system disorders with MCC

Facility

$112,000.00

Service Code	MSDRG 255
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

Upper limb and toe amputation for circulatory system disorders without CC/MCC

Facility

$70,400.00

Service Code	MSDRG 257
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

Urethral procedures with CC/MCC

Facility

$60,800.00

Service Code	MSDRG 671
Min. Negotiated Rate	$26,010.59
Max. Negotiated Rate	$28,900.65
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$28,900.65
Rate for Payer: American Health Plans Medicare Advantage	$28,900.65
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$28,900.65
Rate for Payer: CIGNA Medicare Advantage	$28,900.65
Rate for Payer: HealthChoice Utah Medicare Advantage	$28,900.65
Rate for Payer: Humana Medicare Advantage	$28,900.65
Rate for Payer: Medicare	$28,900.65
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$28,900.65
Rate for Payer: MOLINA MEDICARE	$28,900.65
Rate for Payer: Pacific Source Medicare Advantage	$28,900.65
Rate for Payer: Select Health Medicare Advantage	$28,900.65
Rate for Payer: SELF PAY	$30,400.00
Rate for Payer: Tricare West Military	$26,010.59

Urethral procedures without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 672
Min. Negotiated Rate	$26,010.59
Max. Negotiated Rate	$28,900.65
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$28,900.65
Rate for Payer: American Health Plans Medicare Advantage	$28,900.65
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$28,900.65
Rate for Payer: CIGNA Medicare Advantage	$28,900.65
Rate for Payer: HealthChoice Utah Medicare Advantage	$28,900.65
Rate for Payer: Humana Medicare Advantage	$28,900.65
Rate for Payer: Medicare	$28,900.65
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$28,900.65
Rate for Payer: MOLINA MEDICARE	$28,900.65
Rate for Payer: Pacific Source Medicare Advantage	$28,900.65
Rate for Payer: Select Health Medicare Advantage	$28,900.65
Rate for Payer: SELF PAY	$30,400.00
Rate for Payer: Tricare West Military	$26,010.59

Urethral stricture

Facility

$51,200.00

Service Code	MSDRG 697
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

URIC ACID

Facility

$4.52

Service Code	CPT 84550
Hospital Revenue Code	300
Min. Negotiated Rate	$2.26
Max. Negotiated Rate	$2.26
Rate for Payer: SELF PAY	$2.26

URINAL ADVANTAGE FEMALE W/BAG

Facility

$56.22

Hospital Revenue Code	270
Min. Negotiated Rate	$28.11
Max. Negotiated Rate	$28.11
Rate for Payer: SELF PAY	$28.11

URINALS MALE

Facility

$1.04

Hospital Revenue Code	270
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.52
Rate for Payer: SELF PAY	$0.52

URINALS MALE WP

Facility

$1.04

Hospital Revenue Code	270
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.52
Rate for Payer: SELF PAY	$0.52

URINALYSIS

Facility

$2.17

Service Code	CPT 81005
Hospital Revenue Code	300
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$1.08
Rate for Payer: SELF PAY	$1.08

URINALYSIS COMPLETE

Facility

$115.68

Service Code	CPT 81001
Hospital Revenue Code	300
Min. Negotiated Rate	$57.84
Max. Negotiated Rate	$57.84
Rate for Payer: SELF PAY	$57.84

URINARY DRAIN BAG COVER (PRIVA

Facility

$1.48

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

URINARY DRAIN BAG COVER 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

Know your out-of-pocket cost for care.

All Charges