Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

Urinary stones with MCC

Facility

$60,800.00

Service Code	MSDRG 693
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

Urinary stones without MCC

Facility

$60,800.00

Service Code	MSDRG 694
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

URINE CULTURE

Facility

$154.40

Service Code	CPT 87086
Hospital Revenue Code	300
Min. Negotiated Rate	$77.20
Max. Negotiated Rate	$77.20
Rate for Payer: SELF PAY	$77.20

URINE LEG BAG

Facility

$4.18

Hospital Revenue Code	270
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$2.09
Rate for Payer: SELF PAY	$2.09

URINE LEG BAG WP

Facility

$4.18

Hospital Revenue Code	270
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$2.09
Rate for Payer: SELF PAY	$2.09

URINE OSMOLALITY

Facility

$14.00

Service Code	CPT 83935
Hospital Revenue Code	300
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$7.00
Rate for Payer: SELF PAY	$7.00

URINE SODIUM RANDOM

Facility

$58.28

Service Code	CPT 84300
Hospital Revenue Code	300
Min. Negotiated Rate	$29.14
Max. Negotiated Rate	$29.14
Rate for Payer: SELF PAY	$29.14

Uterine and adnexa procedures for non-malignancy with CC/MCC

Facility

$112,000.00

Service Code	MSDRG 742
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

Uterine and adnexa procedures for non-malignancy without CC/MCC

Facility

$112,000.00

Service Code	MSDRG 743
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

Uterine and adnexa procedures for non-ovarian and non-adnexal malignancy with CC

Facility

$86,400.00

Service Code	MSDRG 740
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

Uterine and adnexa procedures for non-ovarian and non-adnexal malignancy with MCC

Facility

$112,000.00

Service Code	MSDRG 739
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

Uterine and adnexa procedures for non-ovarian and non-adnexal malignancy without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 741
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

Uterine and adnexa procedures for ovarian or adnexal malignancy with CC

Facility

$112,000.00

Service Code	MSDRG 737
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

Uterine and adnexa procedures for ovarian or adnexal malignancy with MCC

Facility

$112,000.00

Service Code	MSDRG 736
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

Uterine and adnexa procedures for ovarian or adnexal malignancy without CC/MCC

Facility

$112,000.00

Service Code	MSDRG 738
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

VAC CANNISTER 500ML

Facility

$93.74

Hospital Revenue Code	270
Min. Negotiated Rate	$46.87
Max. Negotiated Rate	$46.87
Rate for Payer: SELF PAY	$46.87

VAC CANNISTER 500ML WP

Facility

$93.74

Hospital Revenue Code	270
Min. Negotiated Rate	$46.87
Max. Negotiated Rate	$46.87
Rate for Payer: SELF PAY	$46.87

VAC DERMATAC DRAPE

Facility

$52.20

Hospital Revenue Code	270
Min. Negotiated Rate	$26.10
Max. Negotiated Rate	$26.10
Rate for Payer: SELF PAY	$26.10

VAC DERMATAC DRAPE WP

Facility

$52.20

Hospital Revenue Code	270
Min. Negotiated Rate	$26.10
Max. Negotiated Rate	$26.10
Rate for Payer: SELF PAY	$26.10

VAC DRAPE

Facility

$18.00

Hospital Revenue Code	270
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$9.00
Rate for Payer: SELF PAY	$9.00

VAC DRAPE WP

Facility

$36.00

Hospital Revenue Code	270
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$18.00
Rate for Payer: SELF PAY	$18.00

VAC GRANUFORM FOAM KIT MEDIUM

Facility

$75.38

Hospital Revenue Code	270
Min. Negotiated Rate	$37.69
Max. Negotiated Rate	$37.69
Rate for Payer: SELF PAY	$37.69

VAC SENSATRAC FOAM KIT MEDIUM

Facility

$113.06

Hospital Revenue Code	270
Min. Negotiated Rate	$56.53
Max. Negotiated Rate	$56.53
Rate for Payer: SELF PAY	$56.53

VAC SENSATRAC PAD

Facility

$46.42

Hospital Revenue Code	270
Min. Negotiated Rate	$23.21
Max. Negotiated Rate	$23.21
Rate for Payer: SELF PAY	$23.21

VAC SENSATRAC PAD WP

Facility

$46.42

Hospital Revenue Code	270
Min. Negotiated Rate	$23.21
Max. Negotiated Rate	$23.21
Rate for Payer: SELF PAY	$23.21

Know your out-of-pocket cost for care.

All Charges