Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

Nonspecific cerebrovascular disorders without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 72
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 CVA and precerebral occlusion without infarction with MCC

Facility

$73,600.00

Service Code	MSDRG 67
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

Nonspecific CVA and precerebral occlusion without infarction without MCC

Facility

$51,200.00

Service Code	MSDRG 68
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

Nonsterile Tongue Depressor

Facility

$0.04

Hospital Revenue Code	270
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: SELF PAY	$0.02

Nontraumatic stupor and coma with MCC

Facility

$112,000.00

Service Code	MSDRG 80
Min. Negotiated Rate	$62,443.10
Max. Negotiated Rate	$69,381.22
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$69,381.22
Rate for Payer: American Health Plans Medicare Advantage	$69,381.22
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$69,381.22
Rate for Payer: CIGNA Medicare Advantage	$69,381.22
Rate for Payer: HealthChoice Utah Medicare Advantage	$69,381.22
Rate for Payer: Humana Medicare Advantage	$69,381.22
Rate for Payer: Medicare	$69,381.22
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$69,381.22
Rate for Payer: MOLINA MEDICARE	$69,381.22
Rate for Payer: Pacific Source Medicare Advantage	$69,381.22
Rate for Payer: Select Health Medicare Advantage	$69,381.22
Rate for Payer: SELF PAY	$56,000.00
Rate for Payer: Tricare West Military	$62,443.10

Nontraumatic stupor and coma without MCC

Facility

$112,000.00

Service Code	MSDRG 81
Min. Negotiated Rate	$62,443.10
Max. Negotiated Rate	$69,381.22
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$69,381.22
Rate for Payer: American Health Plans Medicare Advantage	$69,381.22
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$69,381.22
Rate for Payer: CIGNA Medicare Advantage	$69,381.22
Rate for Payer: HealthChoice Utah Medicare Advantage	$69,381.22
Rate for Payer: Humana Medicare Advantage	$69,381.22
Rate for Payer: Medicare	$69,381.22
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$69,381.22
Rate for Payer: MOLINA MEDICARE	$69,381.22
Rate for Payer: Pacific Source Medicare Advantage	$69,381.22
Rate for Payer: Select Health Medicare Advantage	$69,381.22
Rate for Payer: SELF PAY	$56,000.00
Rate for Payer: Tricare West Military	$62,443.10

Normal newborn

Facility

$51,200.00

Service Code	MSDRG 795
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

NO-STING SKIN BARRIER SPRAY

Facility

$28.10

Hospital Revenue Code	270
Min. Negotiated Rate	$14.05
Max. Negotiated Rate	$14.05
Rate for Payer: SELF PAY	$14.05

NO-STING SKIN BARRIER SPRAY WP

Facility

$28.10

Hospital Revenue Code	270
Min. Negotiated Rate	$14.05
Max. Negotiated Rate	$14.05
Rate for Payer: SELF PAY	$14.05

Nutramigen

Facility

$14.34

Hospital Revenue Code	270
Min. Negotiated Rate	$7.17
Max. Negotiated Rate	$7.17
Rate for Payer: SELF PAY	$7.17

Nutren Junior with Fiber

Facility

$2.58

Hospital Revenue Code	270
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.29
Rate for Payer: SELF PAY	$1.29

Nutricia Complete Amino Acid M

Facility

$283.08

Hospital Revenue Code	270
Min. Negotiated Rate	$141.54
Max. Negotiated Rate	$141.54
Rate for Payer: SELF PAY	$141.54

O2 BLEED-IN STRAIGHT 22mm W/ST

Facility

$1.72

Hospital Revenue Code	270
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$0.86
Rate for Payer: SELF PAY	$0.86

O2 Concentrator/Day

Facility

$5.60

Hospital Revenue Code	290
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$2.80
Rate for Payer: SELF PAY	$2.80

O2 Flowmeter/Day

Facility

$2.00

Hospital Revenue Code	290
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.00
Rate for Payer: SELF PAY	$1.00

o2 Y CONNECTOR

Facility

$0.16

Hospital Revenue Code	270
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.08
Rate for Payer: SELF PAY	$0.08

OCCULT BLOOD

Facility

$5.32

Service Code	CPT 82271
Hospital Revenue Code	300
Min. Negotiated Rate	$2.66
Max. Negotiated Rate	$2.66
Rate for Payer: SELF PAY	$2.66

OMNI FLEX ADAPTER

Facility

$1.74

Hospital Revenue Code	270
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$0.87
Rate for Payer: SELF PAY	$0.87

OMNI FLEX ADAPTER WP

Facility

$1.74

Hospital Revenue Code	270
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$0.87
Rate for Payer: SELF PAY	$0.87

One on One Attendant per hour

Facility

$25.00

Hospital Revenue Code	769
Min. Negotiated Rate	$12.50
Max. Negotiated Rate	$12.50
Rate for Payer: SELF PAY	$12.50

OPSITE FLEX 2 3/8X 2 3/4

Facility

$0.52

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

OPSITE FLEX 2 3/8X2 3/4 WP

Facility

$0.52

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

OPSITE FLEX 3 3/4 X 3 3/8

Facility

$1.70

Hospital Revenue Code	270
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.85
Rate for Payer: SELF PAY	$0.85

OPSITE FLEX 3 3/4X3 3/8 WP

Facility

$1.70

Hospital Revenue Code	270
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.85
Rate for Payer: SELF PAY	$0.85

OPSITE FLEX 4X4.75

Facility

$2.38

Hospital Revenue Code	270
Min. Negotiated Rate	$1.19
Max. Negotiated Rate	$1.19
Rate for Payer: SELF PAY	$1.19

Know your out-of-pocket cost for care.

All Charges