CMS Price Transparency Data

Varicella (chickenpox) vaccine

Facility: Mountain West Medical Center

Billing Code: 90716 (HCPCS)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 90716
Insurance Median: $309
Cash Discount Price: $247
vs. Medicare Baseline: N/A Medicare

The contracted insurance negotiated median rate for a Varicella (chickenpox) vaccine at Mountain West Medical Center is $309. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $247. Compared to the federal Medicare reimbursement reference rate of N/A, this hospital’s rate is N/A the Medicare baseline. Located in 2055 North Main Street, Tooele, UT.

Cash / Self-Pay

$247

Average discount available for prompt cash payment at this facility.

Insurance Median

$309

Median negotiated contract rate across all mapped commercial carriers.

Medicare Reference Rate

N/A

Standard federal government reimbursement rate for this code.

Out-of-Pocket Cost Estimator

Estimate whether it is more economical to use your insurance or pay the upfront self-pay cash rate.

Billing Status

Remaining Deductible ($)

Your Coinsurance Rate (%)

Input your details and click calculate to compare out-of-pocket costs.

Commercial Insurance Negotiated Rates

Negotiated contract ranges established by major commercial carriers at this facility.

Carrier / Plan Group	Contract Rate Range	vs. Medicare Reference
Wise/Motivhealth-All Plans	$268	N/A
U of Ut-All Plans	$268	N/A
Cigna	$292	N/A
Dmba-All Plans	$297	N/A
Aetna	$309	N/A
Pehp-All Plans	$309	N/A
Select Health-All Other Plans	$309	N/A
Blue Cross Blue Shield	$312	N/A
UnitedHealthcare	$318	N/A
Multiplan Primary Network-All Other Plans	$326	N/A
Emi-All Plans	$351	N/A
Humana	$351	N/A
Multiplan Complimentary Network	$379	N/A

Self-Pay Upfront Cash Action Plan

Request a "Self-Pay classification" with the billing desk before receiving care.
Ask for a written "Prompt-Pay Discount" agreement quoting the price of $247.
Request and sign a "Waiver of Insurance Submission" to prevent automatic billing.
Verify HCPCS Code matches exactly: 90716.

Insurance In-Network Protection Plan

Contact your insurance company to confirm Mountain West Medical Center is fully in-network.
Ask your insurer if "Prior Authorization" is required for HCPCS code 90716.
Confirm the specific physician or imaging center is also in-network (not just the hospital building).
Audit your Explanation of Benefits (EOB) against the final itemized hospital invoice.