Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

EAR CUSHIONS

Facility

$2.06

Hospital Revenue Code	270
Min. Negotiated Rate	$1.03
Max. Negotiated Rate	$1.03
Rate for Payer: SELF PAY	$1.03

EAR CUSHIONS WP

Facility

$2.06

Hospital Revenue Code	270
Min. Negotiated Rate	$1.03
Max. Negotiated Rate	$1.03
Rate for Payer: SELF PAY	$1.03

Ear, nose, mouth and throat malignancy with CC

Facility

$70,400.00

Service Code	MSDRG 147
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

Ear, nose, mouth and throat malignancy with MCC*

Facility

$70,400.00

Service Code	MSDRG 146
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

Ear, nose, mouth and throat malignancy without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 148
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

EARPHONE HEADSET

Facility

$24.00

Hospital Revenue Code	270
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$12.00
Rate for Payer: SELF PAY	$12.00

Echocariography

Facility

$750.00

Hospital Revenue Code	320
Min. Negotiated Rate	$375.00
Max. Negotiated Rate	$375.00
Rate for Payer: SELF PAY	$375.00

ECMO or tracheostomy with MV >96 hours or principal diagnosis except face, mouth and neck with major O.R. procedures

Facility

$188,800.00

Service Code	MSDRG 3
Min. Negotiated Rate	$156,895.83
Max. Negotiated Rate	$174,328.70
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$174,328.70
Rate for Payer: American Health Plans Medicare Advantage	$174,328.70
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$174,328.70
Rate for Payer: CIGNA Medicare Advantage	$174,328.70
Rate for Payer: HealthChoice Utah Medicare Advantage	$174,328.70
Rate for Payer: Humana Medicare Advantage	$174,328.70
Rate for Payer: Medicare	$174,328.70
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$174,328.70
Rate for Payer: MOLINA MEDICARE	$174,328.70
Rate for Payer: Pacific Source Medicare Advantage	$174,328.70
Rate for Payer: Select Health Medicare Advantage	$174,328.70
Rate for Payer: SELF PAY	$94,400.00
Rate for Payer: Tricare West Military	$156,895.83

EFS 1000ml BAG/FLUSH KANGAROO

Facility

$9.50

Hospital Revenue Code	270
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$4.75
Rate for Payer: SELF PAY	$4.75

EKG, 12 LEAD, NUTAB ELECTRODES

Facility

$30.70

Hospital Revenue Code	270
Min. Negotiated Rate	$15.35
Max. Negotiated Rate	$15.35
Rate for Payer: SELF PAY	$15.35

ELECARE

Facility

$55.58

Hospital Revenue Code	270
Min. Negotiated Rate	$27.79
Max. Negotiated Rate	$27.79
Rate for Payer: SELF PAY	$27.79

ELECARE JR

Facility

$55.58

Hospital Revenue Code	270
Min. Negotiated Rate	$27.79
Max. Negotiated Rate	$27.79
Rate for Payer: SELF PAY	$27.79

Electrical Stim 1 unit

Facility

$28.00

Service Code	CPT 97014
Hospital Revenue Code	420
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$14.00
Rate for Payer: SELF PAY	$14.00

Electrical Stimulation

Facility

$26.40

Service Code	CPT G0283
Hospital Revenue Code	430
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$13.20
Rate for Payer: SELF PAY	$13.20

ELECTRIC RAZORS

Facility

$49.94

Hospital Revenue Code	270
Min. Negotiated Rate	$24.97
Max. Negotiated Rate	$24.97
Rate for Payer: SELF PAY	$24.97

ELECTROCHEMILUMINESCENCE

Facility

$10.00

Service Code	CPT 82308
Hospital Revenue Code	300
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$5.00
Rate for Payer: SELF PAY	$5.00

ELECTROLYTES

Facility

$8.05

Service Code	CPT 80051
Hospital Revenue Code	300
Min. Negotiated Rate	$4.03
Max. Negotiated Rate	$4.03
Rate for Payer: SELF PAY	$4.03

EMERY BOARDS

Facility

$0.06

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

EMERY BOARDS 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

EMESIS BASIN

Facility

$0.22

Hospital Revenue Code	270
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.11
Rate for Payer: SELF PAY	$0.11

EMESIS BASIN WP

Facility

$0.22

Hospital Revenue Code	270
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.11
Rate for Payer: SELF PAY	$0.11

Endocrine disorders with CC

Facility

$60,800.00

Service Code	MSDRG 644
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

Endocrine disorders with MCC

Facility

$60,800.00

Service Code	MSDRG 643
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

Endocrine disorders without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 645
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

Endotracheal Tube Introducer B

Facility

$144.28

Hospital Revenue Code	270
Min. Negotiated Rate	$72.14
Max. Negotiated Rate	$72.14
Rate for Payer: SELF PAY	$72.14

Know your out-of-pocket cost for care.

All Charges