Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

Cog Skill Development

Facility

$39.00

Service Code	CPT G0515
Hospital Revenue Code	430
Min. Negotiated Rate	$19.50
Max. Negotiated Rate	$19.50
Rate for Payer: SELF PAY	$19.50

Cog Skill Development 1

Facility

$39.00

Service Code	CPT 97129
Hospital Revenue Code	430
Min. Negotiated Rate	$19.50
Max. Negotiated Rate	$19.50
Rate for Payer: SELF PAY	$19.50

Cog Skill Development 1

Facility

$39.00

Service Code	CPT G0515
Hospital Revenue Code	440
Min. Negotiated Rate	$19.50
Max. Negotiated Rate	$19.50
Rate for Payer: SELF PAY	$19.50

Cog Skill Development 1

Facility

$39.00

Service Code	CPT 97532
Hospital Revenue Code	440
Min. Negotiated Rate	$19.50
Max. Negotiated Rate	$19.50
Rate for Payer: SELF PAY	$19.50

Cog Skill Development 1

Facility

$39.00

Service Code	CPT 97130
Hospital Revenue Code	430
Min. Negotiated Rate	$19.50
Max. Negotiated Rate	$19.50
Rate for Payer: SELF PAY	$19.50

Cog Skill Development 1

Facility

$39.00

Service Code	CPT 97127
Hospital Revenue Code	430
Min. Negotiated Rate	$19.50
Max. Negotiated Rate	$19.50
Rate for Payer: SELF PAY	$19.50

Cog Skill Development 1

Facility

$39.00

Service Code	CPT 97532
Hospital Revenue Code	430
Min. Negotiated Rate	$19.50
Max. Negotiated Rate	$19.50
Rate for Payer: SELF PAY	$19.50

Cog Skill Development 1

Facility

$39.00

Service Code	CPT 97127
Hospital Revenue Code	440
Min. Negotiated Rate	$19.50
Max. Negotiated Rate	$19.50
Rate for Payer: SELF PAY	$19.50

COLLAGEN AG

Facility

$23.84

Hospital Revenue Code	270
Min. Negotiated Rate	$11.92
Max. Negotiated Rate	$11.92
Rate for Payer: SELF PAY	$11.92

COLLAGEN AG WP

Facility

$23.84

Hospital Revenue Code	270
Min. Negotiated Rate	$11.92
Max. Negotiated Rate	$11.92
Rate for Payer: SELF PAY	$11.92

COLOPLAST

Facility

$63.06

Hospital Revenue Code	270
Min. Negotiated Rate	$31.53
Max. Negotiated Rate	$31.53
Rate for Payer: SELF PAY	$31.53

COMB

Facility

$0.06

Hospital Revenue Code	270
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.03
Rate for Payer: SELF PAY	$0.03

Combined anterior and posterior spinal fusion with CC

Facility

$70,400.00

Service Code	MSDRG 454
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

Combined anterior and posterior spinal fusion with MCC

Facility

$67,200.00

Service Code	MSDRG 453
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

Combined anterior and posterior spinal fusion without CC/MCC

Facility

$64,000.00

Service Code	MSDRG 455
Min. Negotiated Rate	$27,594.78
Max. Negotiated Rate	$30,660.87
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$30,660.87
Rate for Payer: American Health Plans Medicare Advantage	$30,660.87
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$30,660.87
Rate for Payer: CIGNA Medicare Advantage	$30,660.87
Rate for Payer: HealthChoice Utah Medicare Advantage	$30,660.87
Rate for Payer: Humana Medicare Advantage	$30,660.87
Rate for Payer: Medicare	$30,660.87
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$30,660.87
Rate for Payer: MOLINA MEDICARE	$30,660.87
Rate for Payer: Pacific Source Medicare Advantage	$30,660.87
Rate for Payer: Select Health Medicare Advantage	$30,660.87
Rate for Payer: SELF PAY	$32,000.00
Rate for Payer: Tricare West Military	$27,594.78

COMB WP

Facility

$0.06

Hospital Revenue Code	270
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.03
Rate for Payer: SELF PAY	$0.03

Compleat Peptide 8oz

Facility

$9.44

Hospital Revenue Code	270
Min. Negotiated Rate	$4.72
Max. Negotiated Rate	$4.72
Rate for Payer: SELF PAY	$4.72

Complex dynamic pharyngeal and speech evaluation by cine or video recording

Facility

$121.28

Service Code	CPT 70371 TC
Hospital Revenue Code	320
Min. Negotiated Rate	$60.64
Max. Negotiated Rate	$60.64
Rate for Payer: SELF PAY	$60.64

Complicated peptic ulcer with CC*

Facility

$70,400.00

Service Code	MSDRG 381
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

Complicated peptic ulcer with MCC

Facility

$70,400.00

Service Code	MSDRG 380
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

Complicated peptic ulcer without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 382
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

Complications of treatment with CC

Facility

$76,800.00

Service Code	MSDRG 920
Min. Negotiated Rate	$30,457.59
Max. Negotiated Rate	$33,841.77
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$33,841.77
Rate for Payer: American Health Plans Medicare Advantage	$33,841.77
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$33,841.77
Rate for Payer: CIGNA Medicare Advantage	$33,841.77
Rate for Payer: HealthChoice Utah Medicare Advantage	$33,841.77
Rate for Payer: Humana Medicare Advantage	$33,841.77
Rate for Payer: Medicare	$33,841.77
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$33,841.77
Rate for Payer: MOLINA MEDICARE	$33,841.77
Rate for Payer: Pacific Source Medicare Advantage	$33,841.77
Rate for Payer: Select Health Medicare Advantage	$33,841.77
Rate for Payer: SELF PAY	$38,400.00
Rate for Payer: Tricare West Military	$30,457.59

Complications of treatment with MCC

Facility

$86,400.00

Service Code	MSDRG 919
Min. Negotiated Rate	$43,822.75
Max. Negotiated Rate	$48,691.95
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$48,691.95
Rate for Payer: American Health Plans Medicare Advantage	$48,691.95
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$48,691.95
Rate for Payer: CIGNA Medicare Advantage	$48,691.95
Rate for Payer: HealthChoice Utah Medicare Advantage	$48,691.95
Rate for Payer: Humana Medicare Advantage	$48,691.95
Rate for Payer: Medicare	$48,691.95
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$48,691.95
Rate for Payer: MOLINA MEDICARE	$48,691.95
Rate for Payer: Pacific Source Medicare Advantage	$48,691.95
Rate for Payer: Select Health Medicare Advantage	$48,691.95
Rate for Payer: SELF PAY	$43,200.00
Rate for Payer: Tricare West Military	$43,822.75

Complications of treatment without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 921
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

Compressed Air Meter/Day

Facility

$10.00

Hospital Revenue Code	290
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$5.00
Rate for Payer: SELF PAY	$5.00

Know your out-of-pocket cost for care.

All Charges