Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

ENFIT NG TUBE 10FR 55"

Facility

$25.02

Hospital Revenue Code	270
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$12.51
Rate for Payer: SELF PAY	$12.51

ENFIT NG TUBE 10FR 55" WP

Facility

$25.02

Hospital Revenue Code	270
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$12.51
Rate for Payer: SELF PAY	$12.51

ENFIT NG TUBE 12FR 55"

Facility

$23.16

Hospital Revenue Code	270
Min. Negotiated Rate	$11.58
Max. Negotiated Rate	$11.58
Rate for Payer: SELF PAY	$11.58

ENFIT NG TUBE 12FR 55" WP

Facility

$23.16

Hospital Revenue Code	270
Min. Negotiated Rate	$11.58
Max. Negotiated Rate	$11.58
Rate for Payer: SELF PAY	$11.58

ENFIT NG TUBE 8FR 43"

Facility

$24.34

Hospital Revenue Code	270
Min. Negotiated Rate	$12.17
Max. Negotiated Rate	$12.17
Rate for Payer: SELF PAY	$12.17

ENFIT NG TUBE 8FR 43" WP

Facility

$23.18

Hospital Revenue Code	270
Min. Negotiated Rate	$11.59
Max. Negotiated Rate	$11.59
Rate for Payer: SELF PAY	$11.59

ENFIT Y-SITE EXTENSION SET

Facility

$3.08

Hospital Revenue Code	270
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$1.54
Rate for Payer: SELF PAY	$1.54

ENFIT Y-SITE EXTENSION SET WP

Facility

$3.08

Hospital Revenue Code	270
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$1.54
Rate for Payer: SELF PAY	$1.54

Epistaxis with MCC

Facility

$51,200.00

Service Code	MSDRG 150
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

Epistaxis without MCC

Facility

$51,200.00

Service Code	MSDRG 151
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

Esophagitis, gastroenteritis and miscellaneous digestive disorders with MCC*

Facility

$64,000.00

Service Code	MSDRG 391
Min. Negotiated Rate	$28,925.67
Max. Negotiated Rate	$32,139.63
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$32,139.63
Rate for Payer: American Health Plans Medicare Advantage	$32,139.63
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$32,139.63
Rate for Payer: CIGNA Medicare Advantage	$32,139.63
Rate for Payer: HealthChoice Utah Medicare Advantage	$32,139.63
Rate for Payer: Humana Medicare Advantage	$32,139.63
Rate for Payer: Medicare	$32,139.63
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$32,139.63
Rate for Payer: MOLINA MEDICARE	$32,139.63
Rate for Payer: Pacific Source Medicare Advantage	$32,139.63
Rate for Payer: Select Health Medicare Advantage	$32,139.63
Rate for Payer: SELF PAY	$32,000.00
Rate for Payer: Tricare West Military	$28,925.67

Esophagitis, gastroenteritis and miscellaneous digestive disorders without MCC*

Facility

$64,000.00

Service Code	MSDRG 392
Min. Negotiated Rate	$28,137.59
Max. Negotiated Rate	$31,263.99
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$31,263.99
Rate for Payer: American Health Plans Medicare Advantage	$31,263.99
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$31,263.99
Rate for Payer: CIGNA Medicare Advantage	$31,263.99
Rate for Payer: HealthChoice Utah Medicare Advantage	$31,263.99
Rate for Payer: Humana Medicare Advantage	$31,263.99
Rate for Payer: Medicare	$31,263.99
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$31,263.99
Rate for Payer: MOLINA MEDICARE	$31,263.99
Rate for Payer: Pacific Source Medicare Advantage	$31,263.99
Rate for Payer: Select Health Medicare Advantage	$31,263.99
Rate for Payer: SELF PAY	$32,000.00
Rate for Payer: Tricare West Military	$28,137.59

ESTRADIOL

Facility

$16.00

Service Code	CPT 82670
Hospital Revenue Code	300
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$8.00
Rate for Payer: SELF PAY	$8.00

ETCO2 MASIMO TRACH ADAPTER

Facility

$33.90

Hospital Revenue Code	270
Min. Negotiated Rate	$16.95
Max. Negotiated Rate	$16.95
Rate for Payer: SELF PAY	$16.95

ETCO2 NC CANNULA MASIMO

Facility

$26.68

Hospital Revenue Code	270
Min. Negotiated Rate	$13.34
Max. Negotiated Rate	$13.34
Rate for Payer: SELF PAY	$13.34

ETCO2 NEO

Facility

$25.80

Hospital Revenue Code	270
Min. Negotiated Rate	$12.90
Max. Negotiated Rate	$12.90
Rate for Payer: SELF PAY	$12.90

ETCO2 SAMPLE NASAL CANNULA

Facility

$42.64

Hospital Revenue Code	270
Min. Negotiated Rate	$21.32
Max. Negotiated Rate	$21.32
Rate for Payer: SELF PAY	$21.32

ETCO2 SAMPLE NASAL CANNULA WP

Facility

$43.22

Hospital Revenue Code	270
Min. Negotiated Rate	$21.61
Max. Negotiated Rate	$21.61
Rate for Payer: SELF PAY	$21.61

ETCO2 SAMPLE TRACH

Facility

$22.36

Hospital Revenue Code	270
Min. Negotiated Rate	$11.18
Max. Negotiated Rate	$11.18
Rate for Payer: SELF PAY	$11.18

ET TRACH TUBE ANCHOR

Facility

$207.14

Hospital Revenue Code	270
Min. Negotiated Rate	$103.57
Max. Negotiated Rate	$103.57
Rate for Payer: SELF PAY	$103.57

Eval for Voice Prosthet

Facility

$86.62

Service Code	CPT 92597
Hospital Revenue Code	440
Min. Negotiated Rate	$43.31
Max. Negotiated Rate	$43.31
Rate for Payer: SELF PAY	$43.31

Eval of Sound production

Facility

$89.85

Service Code	CPT 92522
Hospital Revenue Code	440
Min. Negotiated Rate	$44.92
Max. Negotiated Rate	$44.92
Rate for Payer: SELF PAY	$44.92

Eval of Sound prod w/lan

Facility

$285.00

Service Code	CPT 92523
Hospital Revenue Code	440
Min. Negotiated Rate	$142.50
Max. Negotiated Rate	$142.50
Rate for Payer: SELF PAY	$142.50

Eval of Speech fluency

Facility

$110.41

Service Code	CPT 92521
Hospital Revenue Code	440
Min. Negotiated Rate	$55.20
Max. Negotiated Rate	$55.20
Rate for Payer: SELF PAY	$55.20

Eval of Speech/Lang/Voic

Facility

$155.00

Service Code	CPT 92506
Hospital Revenue Code	440
Min. Negotiated Rate	$77.50
Max. Negotiated Rate	$77.50
Rate for Payer: SELF PAY	$77.50

Know your out-of-pocket cost for care.

All Charges