Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

Resting Tab Electrodes

Facility

$19.18

Hospital Revenue Code	270
Min. Negotiated Rate	$9.59
Max. Negotiated Rate	$9.59
Rate for Payer: SELF PAY	$9.59

RETICULOCYUE COUNT

Facility

$25.88

Hospital Revenue Code	300
Min. Negotiated Rate	$12.94
Max. Negotiated Rate	$12.94
Rate for Payer: SELF PAY	$12.94

Reticuloendothelial and immunity disorders with CC

Facility

$70,400.00

Service Code	MSDRG 815
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

Reticuloendothelial and immunity disorders with MCC

Facility

$70,400.00

Service Code	MSDRG 814
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

Reticuloendothelial and immunity disorders without CC/MCC

Facility

$70,400.00

Service Code	MSDRG 816
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

Revision of hip or knee replacement with CC

Facility

$51,200.00

Service Code	MSDRG 467
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

Revision of hip or knee replacement with MCC

Facility

$86,400.00

Service Code	MSDRG 466
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

Revision of hip or knee replacement without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 468
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

RIGHT ANGLE FEEDING SET Y-PORT

Facility

$79.34

Hospital Revenue Code	270
Min. Negotiated Rate	$39.67
Max. Negotiated Rate	$39.67
Rate for Payer: SELF PAY	$39.67

Room & Board 118

Facility

$3,200.00

Hospital Revenue Code	118
Min. Negotiated Rate	$2,560.00
Max. Negotiated Rate	$2,560.00
Rate for Payer: Provider Network of America	$2,560.00
Rate for Payer: SELF PAY	$1,600.00

Room & Board 206

Facility

$3,200.00

Hospital Revenue Code	206
Min. Negotiated Rate	$850.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AARP MEDICARE COMPLETE (Optum Utah & Nevada)	$1,430.00
Rate for Payer: AETNA-COVENTRY-COFINITY (First Health) (COVENTRY HMO,POS,PPO,ASO,OPM, AUTO INSURANCE MANAGED CARE, NETWORK LEASE) HMO	$850.00
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD/BLUE HPN FEDERAL	$1,600.00
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD/BLUE HPN HMO	$1,600.00
Rate for Payer: CIGNA HMO	$1,350.00
Rate for Payer: Pacific Source Commercial	$850.00
Rate for Payer: Public Employee Health Plan	$1,400.00
Rate for Payer: Select Health Commercial	$1,400.00
Rate for Payer: SELF PAY	$1,600.00
Rate for Payer: University Of Utah HEALTHY ADVANTAGE MCR REPLACEMENT, HEALTHY PREMIER, HEALTHY PREFERRED	$1,450.00
Rate for Payer: University Of Utah Healthy U Medicaid Medicaid	$1,450.00
Rate for Payer: UUHP Mountain Health CO-Op and Montana Health CO-OP MARKETPLACE	$1,450.00

Room & Board Peds

Facility

$3,200.00

Hospital Revenue Code	203
Min. Negotiated Rate	$1,335.00
Max. Negotiated Rate	$1,335.00
Rate for Payer: AETNA-COVENTRY-COFINITY (First Health) (COVENTRY HMO,POS,PPO,ASO,OPM, AUTO INSURANCE MANAGED CARE, NETWORK LEASE) HMO	$1,335.00
Rate for Payer: Pacific Source Commercial	$1,335.00
Rate for Payer: SELF PAY	$1,600.00

Room & Board Private Peds

Facility

$3,200.00

Hospital Revenue Code	110
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,560.00
Rate for Payer: AARP MEDICARE COMPLETE (Optum Utah & Nevada)	$1,430.00
Rate for Payer: DESERET MUTAL BENEFITS ADMINISTRATION (DMBA) HMO	$1,400.00
Rate for Payer: Presbyterian Health Plan Commercial Plans	$1,420.00
Rate for Payer: Presbyterian Health Plan Medicaid	$1,420.00
Rate for Payer: Presbyterian Health Plan Medicare Advantage	$1,420.00
Rate for Payer: Provider Network of America	$2,560.00
Rate for Payer: Select Health Commercial	$1,200.00
Rate for Payer: SELF PAY	$1,600.00
Rate for Payer: University Of Utah HEALTHY ADVANTAGE MCR REPLACEMENT, HEALTHY PREMIER, HEALTHY PREFERRED	$1,200.00
Rate for Payer: University Of Utah Healthy U Medicaid Medicaid	$1,200.00
Rate for Payer: UUHP Mountain Health CO-Op and Montana Health CO-OP MARKETPLACE	$1,200.00

Room & Board Private WP

Facility

$3,200.00

Hospital Revenue Code	110
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,560.00
Rate for Payer: AARP MEDICARE COMPLETE (Optum Utah & Nevada)	$1,430.00
Rate for Payer: DESERET MUTAL BENEFITS ADMINISTRATION (DMBA) HMO	$1,400.00
Rate for Payer: Presbyterian Health Plan Commercial Plans	$1,420.00
Rate for Payer: Presbyterian Health Plan Medicaid	$1,420.00
Rate for Payer: Presbyterian Health Plan Medicare Advantage	$1,420.00
Rate for Payer: Provider Network of America	$2,560.00
Rate for Payer: Select Health Commercial	$1,200.00
Rate for Payer: SELF PAY	$1,600.00
Rate for Payer: University Of Utah HEALTHY ADVANTAGE MCR REPLACEMENT, HEALTHY PREMIER, HEALTHY PREFERRED	$1,200.00
Rate for Payer: University Of Utah Healthy U Medicaid Medicaid	$1,200.00
Rate for Payer: UUHP Mountain Health CO-Op and Montana Health CO-OP MARKETPLACE	$1,200.00

Room & Board Semi-Private Peds

Facility

$3,200.00

Hospital Revenue Code	120
Min. Negotiated Rate	$800.00
Max. Negotiated Rate	$2,560.00
Rate for Payer: AARP MEDICARE COMPLETE (Optum Utah & Nevada)	$1,430.00
Rate for Payer: AETNA-COVENTRY-COFINITY (First Health) (COVENTRY HMO,POS,PPO,ASO,OPM, AUTO INSURANCE MANAGED CARE, NETWORK LEASE) HMO	$800.00
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD/BLUE HPN FEDERAL	$1,400.00
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD/BLUE HPN HMO	$1,400.00
Rate for Payer: CIGNA HMO	$1,250.00
Rate for Payer: Molina Medicaid	$1,293.00
Rate for Payer: Pacific Source Commercial	$800.00
Rate for Payer: Presbyterian Health Plan Commercial Plans	$1,650.00
Rate for Payer: Presbyterian Health Plan Medicaid	$1,650.00
Rate for Payer: Presbyterian Health Plan Medicare Advantage	$1,650.00
Rate for Payer: Provider Network of America	$2,560.00
Rate for Payer: Public Employee Health Plan	$1,200.00
Rate for Payer: SELF PAY	$1,600.00

Room & Board WP

Facility

$3,200.00

Hospital Revenue Code	200
Min. Negotiated Rate	$1,335.00
Max. Negotiated Rate	$1,850.00
Rate for Payer: AARP MEDICARE COMPLETE (Optum Utah & Nevada)	$1,700.00
Rate for Payer: AETNA-COVENTRY-COFINITY (First Health) (COVENTRY HMO,POS,PPO,ASO,OPM, AUTO INSURANCE MANAGED CARE, NETWORK LEASE) HMO	$1,335.00
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD/BLUE HPN FEDERAL	$1,800.00
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD/BLUE HPN HMO	$1,800.00
Rate for Payer: CIGNA HMO	$1,475.00
Rate for Payer: DESERET MUTAL BENEFITS ADMINISTRATION (DMBA) HMO	$1,850.00
Rate for Payer: Pacific Source Commercial	$1,335.00
Rate for Payer: Public Employee Health Plan	$1,700.00
Rate for Payer: Select Health Commercial	$1,700.00
Rate for Payer: SELF PAY	$1,600.00
Rate for Payer: University Of Utah HEALTHY ADVANTAGE MCR REPLACEMENT, HEALTHY PREMIER, HEALTHY PREFERRED	$1,800.00
Rate for Payer: University Of Utah Healthy U Medicaid Medicaid	$1,800.00
Rate for Payer: UUHP Mountain Health CO-Op and Montana Health CO-OP MARKETPLACE	$1,800.00

RT-24 hr One on One

Facility

$1,400.00

Hospital Revenue Code	410
Min. Negotiated Rate	$700.00
Max. Negotiated Rate	$700.00
Rate for Payer: SELF PAY	$700.00

RT Oxygen Over 8 Hours/Day

Facility

$39.60

Hospital Revenue Code	410
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$19.80
Rate for Payer: SELF PAY	$19.80

RT Oxygen Under 8 Hours/Day

Facility

$19.80

Hospital Revenue Code	410
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$9.90
Rate for Payer: SELF PAY	$9.90

R-TRACH BIVONA KID 3.0 FLEXTEN

Facility

$184.00

Hospital Revenue Code	270
Min. Negotiated Rate	$92.00
Max. Negotiated Rate	$92.00
Rate for Payer: SELF PAY	$92.00

R-TRACH BIVONA KID 3.0 PED FLE

Facility

$173.10

Hospital Revenue Code	270
Min. Negotiated Rate	$86.55
Max. Negotiated Rate	$86.55
Rate for Payer: SELF PAY	$86.55

R-TRACH BIVONA KID 3.5 NEO

Facility

$383.30

Hospital Revenue Code	270
Min. Negotiated Rate	$191.65
Max. Negotiated Rate	$191.65
Rate for Payer: SELF PAY	$191.65

R-TRACH BIVONA KID 3.5 NEO(fle

Facility

$335.70

Hospital Revenue Code	270
Min. Negotiated Rate	$167.85
Max. Negotiated Rate	$167.85
Rate for Payer: SELF PAY	$167.85

R-TRACH BIVONA KID 3.5 PED(FLE

Facility

$173.10

Hospital Revenue Code	270
Min. Negotiated Rate	$86.55
Max. Negotiated Rate	$86.55
Rate for Payer: SELF PAY	$86.55

R-TRACH BIVONA KID 4.0 NEO(FLE

Facility

$309.98

Hospital Revenue Code	270
Min. Negotiated Rate	$154.99
Max. Negotiated Rate	$154.99
Rate for Payer: SELF PAY	$154.99

Know your out-of-pocket cost for care.

All Charges