Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

Neonate with other significant problems

Facility

$51,200.00

Service Code	MSDRG 794
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

NEPRO

Facility

$13.50

Hospital Revenue Code	270
Min. Negotiated Rate	$6.75
Max. Negotiated Rate	$6.75
Rate for Payer: SELF PAY	$6.75

NEPRO WP

Facility

$12.26

Hospital Revenue Code	270
Min. Negotiated Rate	$6.13
Max. Negotiated Rate	$6.13
Rate for Payer: SELF PAY	$6.13

NEPTUNE CHAMBER

Facility

$34.72

Hospital Revenue Code	270
Min. Negotiated Rate	$17.36
Max. Negotiated Rate	$17.36
Rate for Payer: SELF PAY	$17.36

NEPTUNE CHAMBER WP

Facility

$34.72

Hospital Revenue Code	270
Min. Negotiated Rate	$17.36
Max. Negotiated Rate	$17.36
Rate for Payer: SELF PAY	$17.36

Neptune heated humidifier 1

Facility

$7.00

Hospital Revenue Code	290
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$3.50
Rate for Payer: SELF PAY	$3.50

NEPTUNE HEATER CORD

Facility

$199.64

Hospital Revenue Code	270
Min. Negotiated Rate	$99.82
Max. Negotiated Rate	$99.82
Rate for Payer: SELF PAY	$99.82

NEPTUNE TEMPERATURE PROBE

Facility

$18.00

Hospital Revenue Code	270
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$9.00
Rate for Payer: SELF PAY	$9.00

NEPTUNE TEMPERATURE PROBE WP

Facility

$18.00

Hospital Revenue Code	270
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$9.00
Rate for Payer: SELF PAY	$9.00

Nervous system neoplasms with MCC

Facility

$60,800.00

Service Code	MSDRG 54
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

Nervous system neoplasms without MCC*

Facility

$60,800.00

Service Code	MSDRG 55
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

Neurological eye disorders

Facility

$51,200.00

Service Code	MSDRG 123
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

Neuromuscular Re-ed

Facility

$49.00

Service Code	CPT 97112
Hospital Revenue Code	420
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$24.50
Rate for Payer: SELF PAY	$24.50

Neuromuscular ReEd (15")

Facility

$49.00

Service Code	CPT 97112
Hospital Revenue Code	430
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$24.50
Rate for Payer: SELF PAY	$24.50

Non-bacterial infection of nervous system except viral meningitis with CC

Facility

$70,400.00

Service Code	MSDRG 98
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

Non-bacterial infection of nervous system except viral meningitis with MCC

Facility

$76,800.00

Service Code	MSDRG 97
Min. Negotiated Rate	$39,440.08
Max. Negotiated Rate	$43,822.31
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$43,822.31
Rate for Payer: American Health Plans Medicare Advantage	$43,822.31
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$43,822.31
Rate for Payer: CIGNA Medicare Advantage	$43,822.31
Rate for Payer: HealthChoice Utah Medicare Advantage	$43,822.31
Rate for Payer: Humana Medicare Advantage	$43,822.31
Rate for Payer: Medicare	$43,822.31
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$43,822.31
Rate for Payer: MOLINA MEDICARE	$43,822.31
Rate for Payer: Pacific Source Medicare Advantage	$43,822.31
Rate for Payer: Select Health Medicare Advantage	$43,822.31
Rate for Payer: SELF PAY	$38,400.00
Rate for Payer: Tricare West Military	$39,440.08

Non-bacterial infection of nervous system except viral meningitis without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 99
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

Non-extensive burns

Facility

$86,400.00

Service Code	MSDRG 935
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

Non-extensive O.R. procedures unrelated to principal diagnosis with CC

Facility

$86,400.00

Service Code	MSDRG 988
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

Non-extensive O.R. procedures unrelated to principal diagnosis with MCC

Facility

$131,200.00

Service Code	MSDRG 987
Min. Negotiated Rate	$95,811.76
Max. Negotiated Rate	$106,457.51
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$106,457.51
Rate for Payer: American Health Plans Medicare Advantage	$106,457.51
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$106,457.51
Rate for Payer: CIGNA Medicare Advantage	$106,457.51
Rate for Payer: HealthChoice Utah Medicare Advantage	$106,457.51
Rate for Payer: Humana Medicare Advantage	$106,457.51
Rate for Payer: Medicare	$106,457.51
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$106,457.51
Rate for Payer: MOLINA MEDICARE	$106,457.51
Rate for Payer: Pacific Source Medicare Advantage	$106,457.51
Rate for Payer: Select Health Medicare Advantage	$106,457.51
Rate for Payer: SELF PAY	$65,600.00
Rate for Payer: Tricare West Military	$95,811.76

Non-extensive O.R. procedures unrelated to principal diagnosis without CC/MCC

Facility

$86,400.00

Service Code	MSDRG 989
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

Non-malignant breast disorders with CC/MCC

Facility

$51,200.00

Service Code	MSDRG 600
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

Non-malignant breast disorders without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 601
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

Nonspecific cerebrovascular disorders with CC

Facility

$60,800.00

Service Code	MSDRG 71
Min. Negotiated Rate	$23,714.70
Max. Negotiated Rate	$26,349.67
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$26,349.67
Rate for Payer: American Health Plans Medicare Advantage	$26,349.67
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$26,349.67
Rate for Payer: CIGNA Medicare Advantage	$26,349.67
Rate for Payer: HealthChoice Utah Medicare Advantage	$26,349.67
Rate for Payer: Humana Medicare Advantage	$26,349.67
Rate for Payer: Medicare	$26,349.67
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$26,349.67
Rate for Payer: MOLINA MEDICARE	$26,349.67
Rate for Payer: Pacific Source Medicare Advantage	$26,349.67
Rate for Payer: Select Health Medicare Advantage	$26,349.67
Rate for Payer: SELF PAY	$30,400.00
Rate for Payer: Tricare West Military	$23,714.70

Nonspecific cerebrovascular disorders with MCC

Facility

$73,600.00

Service Code	MSDRG 70
Min. Negotiated Rate	$35,085.55
Max. Negotiated Rate	$38,983.94
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$38,983.94
Rate for Payer: American Health Plans Medicare Advantage	$38,983.94
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$38,983.94
Rate for Payer: CIGNA Medicare Advantage	$38,983.94
Rate for Payer: HealthChoice Utah Medicare Advantage	$38,983.94
Rate for Payer: Humana Medicare Advantage	$38,983.94
Rate for Payer: Medicare	$38,983.94
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$38,983.94
Rate for Payer: MOLINA MEDICARE	$38,983.94
Rate for Payer: Pacific Source Medicare Advantage	$38,983.94
Rate for Payer: Select Health Medicare Advantage	$38,983.94
Rate for Payer: SELF PAY	$36,800.00
Rate for Payer: Tricare West Military	$35,085.55

Know your out-of-pocket cost for care.

All Charges