Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

Motion fluoroscopic evaluation of swallowing function by cine or video recording

Facility

$180.92

Service Code	CPT 92611 TC
Hospital Revenue Code	320
Min. Negotiated Rate	$90.46
Max. Negotiated Rate	$90.46
Rate for Payer: SELF PAY	$90.46

MOUTH MOISTURIZER

Facility

$3.28

Hospital Revenue Code	270
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$1.64
Rate for Payer: SELF PAY	$1.64

MOUTH MOISTURIZER WP

Facility

$3.28

Hospital Revenue Code	270
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$1.64
Rate for Payer: SELF PAY	$1.64

Mouth procedures with CC/MCC

Facility

$102,400.00

Service Code	MSDRG 137
Min. Negotiated Rate	$60,834.78
Max. Negotiated Rate	$67,594.20
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$67,594.20
Rate for Payer: American Health Plans Medicare Advantage	$67,594.20
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$67,594.20
Rate for Payer: CIGNA Medicare Advantage	$67,594.20
Rate for Payer: HealthChoice Utah Medicare Advantage	$67,594.20
Rate for Payer: Humana Medicare Advantage	$67,594.20
Rate for Payer: Medicare	$67,594.20
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$67,594.20
Rate for Payer: MOLINA MEDICARE	$67,594.20
Rate for Payer: Pacific Source Medicare Advantage	$67,594.20
Rate for Payer: Select Health Medicare Advantage	$67,594.20
Rate for Payer: SELF PAY	$51,200.00
Rate for Payer: Tricare West Military	$60,834.78

Mouth procedures without CC/MCC

Facility

$86,400.00

Service Code	MSDRG 138
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

MOUTHWASH

Facility

$0.50

Hospital Revenue Code	270
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.25
Rate for Payer: SELF PAY	$0.25

MOUTHWASH WP

Facility

$0.50

Hospital Revenue Code	270
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.25
Rate for Payer: SELF PAY	$0.25

MSSA

Facility

$17.70

Service Code	CPT 87081
Hospital Revenue Code	300
Min. Negotiated Rate	$8.85
Max. Negotiated Rate	$8.85
Rate for Payer: SELF PAY	$8.85

Multiple sclerosis and cerebellar ataxia with CC

Facility

$76,800.00

Service Code	MSDRG 59
Min. Negotiated Rate	$27,156.52
Max. Negotiated Rate	$30,173.91
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$30,173.91
Rate for Payer: American Health Plans Medicare Advantage	$30,173.91
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$30,173.91
Rate for Payer: CIGNA Medicare Advantage	$30,173.91
Rate for Payer: HealthChoice Utah Medicare Advantage	$30,173.91
Rate for Payer: Humana Medicare Advantage	$30,173.91
Rate for Payer: Medicare	$30,173.91
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$30,173.91
Rate for Payer: MOLINA MEDICARE	$30,173.91
Rate for Payer: Pacific Source Medicare Advantage	$30,173.91
Rate for Payer: Select Health Medicare Advantage	$30,173.91
Rate for Payer: SELF PAY	$38,400.00
Rate for Payer: Tricare West Military	$27,156.52

Multiple sclerosis and cerebellar ataxia with MCC

Facility

$86,400.00

Service Code	MSDRG 58
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

Multiple sclerosis and cerebellar ataxia without CC/MCC

Facility

$76,800.00

Service Code	MSDRG 60
Min. Negotiated Rate	$27,156.52
Max. Negotiated Rate	$30,173.91
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$30,173.91
Rate for Payer: American Health Plans Medicare Advantage	$30,173.91
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$30,173.91
Rate for Payer: CIGNA Medicare Advantage	$30,173.91
Rate for Payer: HealthChoice Utah Medicare Advantage	$30,173.91
Rate for Payer: Humana Medicare Advantage	$30,173.91
Rate for Payer: Medicare	$30,173.91
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$30,173.91
Rate for Payer: MOLINA MEDICARE	$30,173.91
Rate for Payer: Pacific Source Medicare Advantage	$30,173.91
Rate for Payer: Select Health Medicare Advantage	$30,173.91
Rate for Payer: SELF PAY	$38,400.00
Rate for Payer: Tricare West Military	$27,156.52

MULTI-PODUS BOOT MEDIUM/LARGE

Facility

$232.78

Hospital Revenue Code	270
Min. Negotiated Rate	$116.39
Max. Negotiated Rate	$116.39
Rate for Payer: SELF PAY	$116.39

MULTI-PODUS BOOT MPO-2000 SMAL

Facility

$139.00

Hospital Revenue Code	270
Min. Negotiated Rate	$69.50
Max. Negotiated Rate	$69.50
Rate for Payer: SELF PAY	$69.50

MULTI-PODUS BOOT SMALL/MEDIUM

Facility

$240.06

Hospital Revenue Code	270
Min. Negotiated Rate	$120.03
Max. Negotiated Rate	$120.03
Rate for Payer: SELF PAY	$120.03

Myeloproliferative disorders or poorly differentiated neoplasms with major O.R. procedures with CC

Facility

$86,400.00

Service Code	MSDRG 827
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

Myeloproliferative disorders or poorly differentiated neoplasms with major O.R. procedures with MCC

Facility

$115,200.00

Service Code	MSDRG 826
Min. Negotiated Rate	$54,489.95
Max. Negotiated Rate	$60,544.39
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$60,544.39
Rate for Payer: American Health Plans Medicare Advantage	$60,544.39
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$60,544.39
Rate for Payer: CIGNA Medicare Advantage	$60,544.39
Rate for Payer: HealthChoice Utah Medicare Advantage	$60,544.39
Rate for Payer: Humana Medicare Advantage	$60,544.39
Rate for Payer: Medicare	$60,544.39
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$60,544.39
Rate for Payer: MOLINA MEDICARE	$60,544.39
Rate for Payer: Pacific Source Medicare Advantage	$60,544.39
Rate for Payer: Select Health Medicare Advantage	$60,544.39
Rate for Payer: SELF PAY	$57,600.00
Rate for Payer: Tricare West Military	$54,489.95

Myeloproliferative disorders or poorly differentiated neoplasms with major O.R. procedures without CC/MCC

Facility

$86,400.00

Service Code	MSDRG 828
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

Myeloproliferative disorders or poorly differentiated neoplasms with other procedures with CC/MCC

Facility

$70,400.00

Service Code	MSDRG 829
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

Myeloproliferative disorders or poorly differentiated neoplasms with other procedures without CC/MCC

Facility

$70,400.00

Service Code	MSDRG 830
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

N1H1 (Swine Flu)

Facility

$27.60

Service Code	CPT 87400
Hospital Revenue Code	300
Min. Negotiated Rate	$13.80
Max. Negotiated Rate	$13.80
Rate for Payer: SELF PAY	$13.80

N95 3M 1860

Facility

$24.86

Hospital Revenue Code	270
Min. Negotiated Rate	$12.43
Max. Negotiated Rate	$12.43
Rate for Payer: SELF PAY	$12.43

N95 3M 8210

Facility

$41.26

Hospital Revenue Code	270
Min. Negotiated Rate	$20.63
Max. Negotiated Rate	$20.63
Rate for Payer: SELF PAY	$20.63

N95 3M 9502+

Facility

$70.00

Hospital Revenue Code	270
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$35.00
Rate for Payer: SELF PAY	$35.00

N95 3M AURA 9210+

Facility

$3.10

Hospital Revenue Code	270
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$1.55
Rate for Payer: SELF PAY	$1.55

N95 Aura 9205+

Facility

$3.24

Hospital Revenue Code	270
Min. Negotiated Rate	$1.62
Max. Negotiated Rate	$1.62
Rate for Payer: SELF PAY	$1.62

Know your out-of-pocket cost for care.

All Charges