Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

Malignant breast disorders with MCC

Facility

$86,400.00

Service Code	MSDRG 597
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

Malignant breast disorders without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 599
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

Manual Therapy (1 unit)

Facility

$44.00

Service Code	CPT 97140
Hospital Revenue Code	420
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$22.00
Rate for Payer: SELF PAY	$22.00

Manual Therapy 1 unit

Facility

$44.00

Service Code	CPT 97140
Hospital Revenue Code	430
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$22.00
Rate for Payer: SELF PAY	$22.00

MASK AEROSOL ADULT

Facility

$0.82

Hospital Revenue Code	270
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.41
Rate for Payer: SELF PAY	$0.41

MASK AEROSOL ADULT WP

Facility

$0.82

Hospital Revenue Code	270
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.41
Rate for Payer: SELF PAY	$0.41

MASK AEROSOL PEDIATRIC

Facility

$1.20

Hospital Revenue Code	270
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: SELF PAY	$0.60

MASK NONREBREATHER ADULT

Facility

$2.26

Hospital Revenue Code	270
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.13
Rate for Payer: SELF PAY	$1.13

MASK NONREBREATHER ADULT WP

Facility

$2.26

Hospital Revenue Code	270
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.13
Rate for Payer: SELF PAY	$1.13

MASK NONREBREATHER PEDIATRIC

Facility

$3.26

Hospital Revenue Code	270
Min. Negotiated Rate	$1.63
Max. Negotiated Rate	$1.63
Rate for Payer: SELF PAY	$1.63

MASK W/ SAFETY SHIELD COMBO

Facility

$60.96

Hospital Revenue Code	270
Min. Negotiated Rate	$30.48
Max. Negotiated Rate	$30.48
Rate for Payer: SELF PAY	$30.48

MASK W/ SAFETY SHIELD COMBO WP

Facility

$60.96

Hospital Revenue Code	270
Min. Negotiated Rate	$30.48
Max. Negotiated Rate	$30.48
Rate for Payer: SELF PAY	$30.48

Mastectomy for malignancy with CC/MCC

Facility

$89,600.00

Service Code	MSDRG 582
Min. Negotiated Rate	$38,056.91
Max. Negotiated Rate	$42,285.46
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$42,285.46
Rate for Payer: American Health Plans Medicare Advantage	$42,285.46
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$42,285.46
Rate for Payer: CIGNA Medicare Advantage	$42,285.46
Rate for Payer: HealthChoice Utah Medicare Advantage	$42,285.46
Rate for Payer: Humana Medicare Advantage	$42,285.46
Rate for Payer: Medicare	$42,285.46
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$42,285.46
Rate for Payer: MOLINA MEDICARE	$42,285.46
Rate for Payer: Pacific Source Medicare Advantage	$42,285.46
Rate for Payer: Select Health Medicare Advantage	$42,285.46
Rate for Payer: SELF PAY	$44,800.00
Rate for Payer: Tricare West Military	$38,056.91

Mastectomy for malignancy without CC/MCC

Facility

$89,600.00

Service Code	MSDRG 583
Min. Negotiated Rate	$38,056.91
Max. Negotiated Rate	$42,285.46
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$42,285.46
Rate for Payer: American Health Plans Medicare Advantage	$42,285.46
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$42,285.46
Rate for Payer: CIGNA Medicare Advantage	$42,285.46
Rate for Payer: HealthChoice Utah Medicare Advantage	$42,285.46
Rate for Payer: Humana Medicare Advantage	$42,285.46
Rate for Payer: Medicare	$42,285.46
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$42,285.46
Rate for Payer: MOLINA MEDICARE	$42,285.46
Rate for Payer: Pacific Source Medicare Advantage	$42,285.46
Rate for Payer: Select Health Medicare Advantage	$42,285.46
Rate for Payer: SELF PAY	$44,800.00
Rate for Payer: Tricare West Military	$38,056.91

MaxiPad

Facility

$0.52

Hospital Revenue Code	270
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.26
Rate for Payer: SELF PAY	$0.26

Maxorb 1 x12 Rope

Facility

$10.78

Hospital Revenue Code	270
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$5.39
Rate for Payer: SELF PAY	$5.39

Maxorb 1x12 Rope WP

Facility

$10.78

Hospital Revenue Code	270
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$5.39
Rate for Payer: SELF PAY	$5.39

Maxorb 4x4 Alginate

Facility

$6.32

Hospital Revenue Code	270
Min. Negotiated Rate	$3.16
Max. Negotiated Rate	$3.16
Rate for Payer: SELF PAY	$3.16

Maxorb 4X4 Alginate WP

Facility

$6.32

Hospital Revenue Code	270
Min. Negotiated Rate	$3.16
Max. Negotiated Rate	$3.16
Rate for Payer: SELF PAY	$3.16

MAXORB EXTRA CMC 4X8"

Facility

$9.32

Hospital Revenue Code	270
Min. Negotiated Rate	$4.66
Max. Negotiated Rate	$4.66
Rate for Payer: SELF PAY	$4.66

MDI ADAPTER COUNTER

Facility

$12.20

Hospital Revenue Code	270
Min. Negotiated Rate	$6.10
Max. Negotiated Rate	$6.10
Rate for Payer: SELF PAY	$6.10

MDI ADAPTER COUNTER WP

Facility

$12.20

Hospital Revenue Code	270
Min. Negotiated Rate	$6.10
Max. Negotiated Rate	$6.10
Rate for Payer: SELF PAY	$6.10

MEASURING PAPER TAPE WP

Facility

$0.32

Hospital Revenue Code	270
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.16
Rate for Payer: SELF PAY	$0.16

MEASURING TAPE

Facility

$0.32

Hospital Revenue Code	270
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.16
Rate for Payer: SELF PAY	$0.16

MEDELA CANISTER 300cc

Facility

$42.52

Hospital Revenue Code	270
Min. Negotiated Rate	$21.26
Max. Negotiated Rate	$21.26
Rate for Payer: SELF PAY	$21.26

Know your out-of-pocket cost for care.

All Charges