Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

Eval of Swallowing/Oral

Facility

$155.00

Service Code	CPT 92610
Hospital Revenue Code	440
Min. Negotiated Rate	$77.50
Max. Negotiated Rate	$77.50
Rate for Payer: SELF PAY	$77.50

EXHALATION PORT

Facility

$10.26

Hospital Revenue Code	270
Min. Negotiated Rate	$5.13
Max. Negotiated Rate	$5.13
Rate for Payer: SELF PAY	$5.13

EXHALATION VALVE (DISPOSIBLE)

Facility

$8.92

Hospital Revenue Code	270
Min. Negotiated Rate	$4.46
Max. Negotiated Rate	$4.46
Rate for Payer: SELF PAY	$4.46

Ext Developmental Testin

Facility

$127.46

Service Code	CPT 96111
Hospital Revenue Code	440
Min. Negotiated Rate	$63.73
Max. Negotiated Rate	$63.73
Rate for Payer: SELF PAY	$63.73

Extensive burns or full thickness burns with MV >96 hours without skin graft

Facility

$51,200.00

Service Code	MSDRG 933
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

Extensive burns or full thickness burns with MV >96 hours with skin graft

Facility

$51,200.00

Service Code	MSDRG 927
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

Extensive O.R. procedures unrelated to principal diagnosis with CC

Facility

$89,600.00

Service Code	MSDRG 982
Min. Negotiated Rate	$49,749.42
Max. Negotiated Rate	$55,277.13
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$55,277.13
Rate for Payer: American Health Plans Medicare Advantage	$55,277.13
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$55,277.13
Rate for Payer: CIGNA Medicare Advantage	$55,277.13
Rate for Payer: HealthChoice Utah Medicare Advantage	$55,277.13
Rate for Payer: Humana Medicare Advantage	$55,277.13
Rate for Payer: Medicare	$55,277.13
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$55,277.13
Rate for Payer: MOLINA MEDICARE	$55,277.13
Rate for Payer: Pacific Source Medicare Advantage	$55,277.13
Rate for Payer: Select Health Medicare Advantage	$55,277.13
Rate for Payer: SELF PAY	$44,800.00
Rate for Payer: Tricare West Military	$49,749.42

Extensive O.R. procedures unrelated to principal diagnosis with MCC

Facility

$134,400.00

Service Code	MSDRG 981
Min. Negotiated Rate	$99,655.65
Max. Negotiated Rate	$110,728.50
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$110,728.50
Rate for Payer: American Health Plans Medicare Advantage	$110,728.50
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$110,728.50
Rate for Payer: CIGNA Medicare Advantage	$110,728.50
Rate for Payer: HealthChoice Utah Medicare Advantage	$110,728.50
Rate for Payer: Humana Medicare Advantage	$110,728.50
Rate for Payer: Medicare	$110,728.50
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$110,728.50
Rate for Payer: MOLINA MEDICARE	$110,728.50
Rate for Payer: Pacific Source Medicare Advantage	$110,728.50
Rate for Payer: Select Health Medicare Advantage	$110,728.50
Rate for Payer: SELF PAY	$67,200.00
Rate for Payer: Tricare West Military	$99,655.65

Extensive O.R. procedures unrelated to principal diagnosis without CC/MCC

Facility

$86,400.00

Service Code	MSDRG 983
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

EXTERNAL BACTERIAL FILTER VOCS

Facility

$6.20

Hospital Revenue Code	270
Min. Negotiated Rate	$3.10
Max. Negotiated Rate	$3.10
Rate for Payer: SELF PAY	$3.10

Extracranial procedures with CC

Facility

$86,400.00

Service Code	MSDRG 38
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

Extracranial procedures with MCC

Facility

$86,400.00

Service Code	MSDRG 37
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

Extracranial procedures without CC/MCC

Facility

$86,400.00

Service Code	MSDRG 39
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

Extraocular procedures except orbit

Facility

$86,400.00

Service Code	MSDRG 115
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

Extreme immaturity or respiratory distress syndrome, neonate

Facility

$51,200.00

Service Code	MSDRG 790
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

EZ SCRUB BRUSH 160

Facility

$2.02

Hospital Revenue Code	270
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$1.01
Rate for Payer: SELF PAY	$1.01

EZWAY DISPOSABLE SLING LARGE

Facility

$100.62

Hospital Revenue Code	270
Min. Negotiated Rate	$50.31
Max. Negotiated Rate	$50.31
Rate for Payer: SELF PAY	$50.31

EZWAY DISPOSABLE SLING LARGE W

Facility

$100.62

Hospital Revenue Code	270
Min. Negotiated Rate	$50.31
Max. Negotiated Rate	$50.31
Rate for Payer: SELF PAY	$50.31

EZWAY DISPOSABLE SLING MED

Facility

$97.14

Hospital Revenue Code	270
Min. Negotiated Rate	$48.57
Max. Negotiated Rate	$48.57
Rate for Payer: SELF PAY	$48.57

EZWAY DISPOSABLE SLING MEDIUM

Facility

$97.14

Hospital Revenue Code	270
Min. Negotiated Rate	$48.57
Max. Negotiated Rate	$48.57
Rate for Payer: SELF PAY	$48.57

EZWAY DISPOSABLE SLING XL

Facility

$102.76

Hospital Revenue Code	270
Min. Negotiated Rate	$51.38
Max. Negotiated Rate	$51.38
Rate for Payer: SELF PAY	$51.38

EZWAY DISPOSABLE SLING XL WP

Facility

$102.76

Hospital Revenue Code	270
Min. Negotiated Rate	$51.38
Max. Negotiated Rate	$51.38
Rate for Payer: SELF PAY	$51.38

EZ WRAP

Facility

$1.06

Hospital Revenue Code	270
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.53
Rate for Payer: SELF PAY	$0.53

EZ WRAP WP

Facility

$1.06

Hospital Revenue Code	270
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.53
Rate for Payer: SELF PAY	$0.53

face Mask

Facility

$40.00

Hospital Revenue Code	270
Min. Negotiated Rate	$20.00
Max. Negotiated Rate	$20.00
Rate for Payer: SELF PAY	$20.00

Know your out-of-pocket cost for care.

All Charges