Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

BATTERY GLUCOMETER

Facility

$1.20

Hospital Revenue Code	270
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: SELF PAY	$0.60

BATTERY GLUCOMETER WP

Facility

$1.20

Hospital Revenue Code	270
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: SELF PAY	$0.60

BBG NASAL ASPIRATOR

Facility

$6.02

Hospital Revenue Code	270
Min. Negotiated Rate	$3.01
Max. Negotiated Rate	$3.01
Rate for Payer: SELF PAY	$3.01

BBG NASAL ASPIRATOR WP

Facility

$6.02

Hospital Revenue Code	270
Min. Negotiated Rate	$3.01
Max. Negotiated Rate	$3.01
Rate for Payer: SELF PAY	$3.01

BED CHUX

Facility

$3.76

Hospital Revenue Code	270
Min. Negotiated Rate	$1.88
Max. Negotiated Rate	$1.88
Rate for Payer: SELF PAY	$1.88

BED PAN FRACTURE

Facility

$3.00

Hospital Revenue Code	270
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$1.50
Rate for Payer: SELF PAY	$1.50

BED PAN FRACTURE WP

Facility

$3.00

Hospital Revenue Code	270
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$1.50
Rate for Payer: SELF PAY	$1.50

BED PAN STACKABLE

Facility

$0.08

Hospital Revenue Code	270
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.04
Rate for Payer: SELF PAY	$0.04

BED PAN STACKABLE WP

Facility

$4.32

Hospital Revenue Code	270
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$2.16
Rate for Payer: SELF PAY	$2.16

Behav and qualit analysi

Facility

$100.00

Service Code	CPT 92524
Hospital Revenue Code	440
Min. Negotiated Rate	$50.00
Max. Negotiated Rate	$50.00
Rate for Payer: SELF PAY	$50.00

BENEPROTEIN 8oz.

Facility

$25.22

Hospital Revenue Code	270
Min. Negotiated Rate	$12.61
Max. Negotiated Rate	$12.61
Rate for Payer: SELF PAY	$12.61

Benign prostatic hypertrophy with MCC

Facility

$60,800.00

Service Code	MSDRG 725
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

Benign prostatic hypertrophy without MCC

Facility

$60,800.00

Service Code	MSDRG 726
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

Bilateral or multiple major joint procedures of lower extremity with MCC

Facility

$67,200.00

Service Code	MSDRG 461
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

Bilateral or multiple major joint procedures of lower extremity without MCC

Facility

$70,400.00

Service Code	MSDRG 462
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

Biliary tract procedures except only cholecystectomy with or without C.D.E. with CC

Facility

$51,200.00

Service Code	MSDRG 409
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

Biliary tract procedures except only cholecystectomy with or without C.D.E. with MCC

Facility

$70,400.00

Service Code	MSDRG 408
Min. Negotiated Rate	$30,972.26
Max. Negotiated Rate	$34,413.62
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$34,413.62
Rate for Payer: American Health Plans Medicare Advantage	$34,413.62
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$34,413.62
Rate for Payer: CIGNA Medicare Advantage	$34,413.62
Rate for Payer: HealthChoice Utah Medicare Advantage	$34,413.62
Rate for Payer: Humana Medicare Advantage	$34,413.62
Rate for Payer: Medicare	$34,413.62
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$34,413.62
Rate for Payer: MOLINA MEDICARE	$34,413.62
Rate for Payer: Pacific Source Medicare Advantage	$34,413.62
Rate for Payer: Select Health Medicare Advantage	$34,413.62
Rate for Payer: SELF PAY	$35,200.00
Rate for Payer: Tricare West Military	$30,972.26

Biliary tract procedures except only cholecystectomy with or without C.D.E. without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 410
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

Biopsies of musculoskeletal system and connective tissue with CC

Facility

$67,200.00

Service Code	MSDRG 478
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

Biopsies of musculoskeletal system and connective tissue with MCC

Facility

$86,400.00

Service Code	MSDRG 477
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

Biopsies of musculoskeletal system and connective tissue without CC/MCC

Facility

$67,200.00

Service Code	MSDRG 479
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

BIVONA CUFFED TRACH 5.0

Facility

$202.92

Hospital Revenue Code	270
Min. Negotiated Rate	$101.46
Max. Negotiated Rate	$101.46
Rate for Payer: SELF PAY	$101.46

BIVONA CUFFED TRACH 5.0 PED

Facility

$550.34

Hospital Revenue Code	270
Min. Negotiated Rate	$275.17
Max. Negotiated Rate	$275.17
Rate for Payer: SELF PAY	$275.17

BIVONA CUFFED TRACH 6.0

Facility

$180.14

Hospital Revenue Code	270
Min. Negotiated Rate	$90.07
Max. Negotiated Rate	$90.07
Rate for Payer: SELF PAY	$90.07

BIVONA CUFFED TRACH 6.0 PED

Facility

$506.86

Hospital Revenue Code	270
Min. Negotiated Rate	$253.43
Max. Negotiated Rate	$253.43
Rate for Payer: SELF PAY	$253.43

Know your out-of-pocket cost for care.

All Charges