Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

Cortrak Nasogastric / Nasointe

Facility

$310.62

Hospital Revenue Code	270
Min. Negotiated Rate	$155.31
Max. Negotiated Rate	$155.31
Rate for Payer: SELF PAY	$155.31

COTTON TIP APPLICATOR 6" STERI

Facility

$0.08

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

COTTON TIP APPLICATOR NS 3"

Facility

$0.94

Hospital Revenue Code	270
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.47
Rate for Payer: SELF PAY	$0.47

COTTON TIP APPLICATOR NS 3" WP

Facility

$0.94

Hospital Revenue Code	270
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.47
Rate for Payer: SELF PAY	$0.47

COTTON TIP APPLICATOR NS 6"

Facility

$1.24

Hospital Revenue Code	270
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.62
Rate for Payer: SELF PAY	$0.62

Cough Assist Machine

Facility

$23.00

Hospital Revenue Code	290
Min. Negotiated Rate	$11.50
Max. Negotiated Rate	$11.50
Rate for Payer: SELF PAY	$11.50

COVID-19 (PCR)

Facility

$50.00

Service Code	CPT U0001
Hospital Revenue Code	300
Min. Negotiated Rate	$25.00
Max. Negotiated Rate	$25.00
Rate for Payer: SELF PAY	$25.00

COVID-19 (Rapid-Abbott)

Facility

$56.11

Service Code	CPT 87811
Hospital Revenue Code	300
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$28.05
Rate for Payer: SELF PAY	$28.05

COVID-19 (Rapid-BD)

Facility

$50.00

Service Code	CPT 87426
Hospital Revenue Code	300
Min. Negotiated Rate	$25.00
Max. Negotiated Rate	$25.00
Rate for Payer: SELF PAY	$25.00

CPAP Mask Kit ComfortGel Mediu

Facility

$173.46

Hospital Revenue Code	270
Min. Negotiated Rate	$86.73
Max. Negotiated Rate	$86.73
Rate for Payer: SELF PAY	$86.73

CPAP Wipes

Facility

$13.72

Hospital Revenue Code	270
Min. Negotiated Rate	$6.86
Max. Negotiated Rate	$6.86
Rate for Payer: SELF PAY	$6.86

CPAP Wipes WP

Facility

$164.58

Hospital Revenue Code	270
Min. Negotiated Rate	$82.29
Max. Negotiated Rate	$82.29
Rate for Payer: SELF PAY	$82.29

CPM Machine

Facility

$37.50

Hospital Revenue Code	290
Min. Negotiated Rate	$18.75
Max. Negotiated Rate	$18.75
Rate for Payer: SELF PAY	$18.75

CPR Stat Padz

Facility

$179.06

Hospital Revenue Code	270
Min. Negotiated Rate	$89.53
Max. Negotiated Rate	$89.53
Rate for Payer: SELF PAY	$89.53

CPR Stat-Padz Electrodes AED

Facility

$244.52

Hospital Revenue Code	270
Min. Negotiated Rate	$122.26
Max. Negotiated Rate	$122.26
Rate for Payer: SELF PAY	$122.26

Cranial and peripheral nerve disorders with MCC

Facility

$70,400.00

Service Code	MSDRG 73
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

Cranial and peripheral nerve disorders without MCC

Facility

$51,200.00

Service Code	MSDRG 74
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

Craniotomy and endovascular intracranial procedures with CC

Facility

$112,000.00

Service Code	MSDRG 26
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

Craniotomy and endovascular intracranial procedures with MCC

Facility

$112,000.00

Service Code	MSDRG 25
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

Craniotomy and endovascular intracranial procedures without CC/MCC

Facility

$112,000.00

Service Code	MSDRG 27
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

Craniotomy for multiple significant trauma

Facility

$86,400.00

Service Code	MSDRG 955
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

Craniotomy with major device implant or acute complex CNS principal diagnosis with MCC or chemotherapy implant or epilepsy with neurostimulator

Facility

$112,000.00

Service Code	MSDRG 23
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

Craniotomy with major device implant or acute complex CNS principal diagnosis without MCC

Facility

$112,000.00

Service Code	MSDRG 24
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

C REACTIVE PROTEIN

Facility

$48.00

Service Code	CPT 86140
Hospital Revenue Code	300
Min. Negotiated Rate	$24.00
Max. Negotiated Rate	$24.00
Rate for Payer: SELF PAY	$24.00

CREATINE KINASE

Facility

$21.00

Service Code	CPT 82550
Hospital Revenue Code	300
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$10.50
Rate for Payer: SELF PAY	$10.50

Know your out-of-pocket cost for care.

All Charges