Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

5 in 1 Tubing Connector

Facility

$0.82

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

60cc FLAT TOP SYRINGE

Facility

$1.32

Hospital Revenue Code	270
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.66
Rate for Payer: SELF PAY	$0.66

70mm UROSTOMY TRANSPARENT POUC

Facility

$4.94

Hospital Revenue Code	270
Min. Negotiated Rate	$2.47
Max. Negotiated Rate	$2.47
Rate for Payer: SELF PAY	$2.47

7.5 mm ET Tube

Facility

$12.16

Hospital Revenue Code	270
Min. Negotiated Rate	$6.08
Max. Negotiated Rate	$6.08
Rate for Payer: SELF PAY	$6.08

7FR SUCTION BALLARD

Facility

$35.02

Hospital Revenue Code	270
Min. Negotiated Rate	$17.51
Max. Negotiated Rate	$17.51
Rate for Payer: SELF PAY	$17.51

80 mm Disposable Green Guedel

Facility

$0.60

Hospital Revenue Code	270
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.30
Rate for Payer: SELF PAY	$0.30

8.0 mm ET Tube

Facility

$12.16

Hospital Revenue Code	270
Min. Negotiated Rate	$6.08
Max. Negotiated Rate	$6.08
Rate for Payer: SELF PAY	$6.08

8.5 mm ET Tube

Facility

$18.22

Hospital Revenue Code	270
Min. Negotiated Rate	$9.11
Max. Negotiated Rate	$9.11
Rate for Payer: SELF PAY	$9.11

90 mm Disposable Yellow Guedel

Facility

$0.60

Hospital Revenue Code	270
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.30
Rate for Payer: SELF PAY	$0.30

ABDOMINAL BINDER LARGE 60"x75"

Facility

$26.34

Hospital Revenue Code	270
Min. Negotiated Rate	$13.17
Max. Negotiated Rate	$13.17
Rate for Payer: SELF PAY	$13.17

ABDOMINAL BINDER MEDIUM 45"x62

Facility

$18.94

Hospital Revenue Code	270
Min. Negotiated Rate	$9.47
Max. Negotiated Rate	$9.47
Rate for Payer: SELF PAY	$9.47

ABDOMINAL BINDER SMALL 30"x45"

Facility

$17.74

Hospital Revenue Code	270
Min. Negotiated Rate	$8.87
Max. Negotiated Rate	$8.87
Rate for Payer: SELF PAY	$8.87

ABD PADS 5X9

Facility

$0.30

Hospital Revenue Code	270
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.15
Rate for Payer: SELF PAY	$0.15

ABD PADS 5X9 WP

Facility

$0.30

Hospital Revenue Code	270
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.15
Rate for Payer: SELF PAY	$0.15

ABG

Facility

$22.30

Service Code	CPT 82805
Hospital Revenue Code	300
Min. Negotiated Rate	$11.15
Max. Negotiated Rate	$11.15
Rate for Payer: SELF PAY	$11.15

ABG (Arterial Blood Gas)

Facility

$22.30

Service Code	CPT 82805
Hospital Revenue Code	300
Min. Negotiated Rate	$11.15
Max. Negotiated Rate	$11.15
Rate for Payer: SELF PAY	$11.15

ABG KIT

Facility

$3.02

Hospital Revenue Code	270
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$1.51
Rate for Payer: SELF PAY	$1.51

ABG KIT WP

Facility

$3.02

Hospital Revenue Code	270
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$1.51
Rate for Payer: SELF PAY	$1.51

Abortion with D&C, aspiration curettage or hysterotomy

Facility

$51,200.00

Service Code	MSDRG 770
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

Abortion without D&C

Facility

$51,200.00

Service Code	MSDRG 779
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

ACE BANDAGE W/VELCRO 4"

Facility

$2.74

Hospital Revenue Code	270
Min. Negotiated Rate	$1.37
Max. Negotiated Rate	$1.37
Rate for Payer: SELF PAY	$1.37

ACE BANDAGE W/VELCRO 4" WP

Facility

$2.74

Hospital Revenue Code	270
Min. Negotiated Rate	$1.37
Max. Negotiated Rate	$1.37
Rate for Payer: SELF PAY	$1.37

ACE BANDAGE W/VELCRO 6"

Facility

$4.36

Hospital Revenue Code	270
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$2.18
Rate for Payer: SELF PAY	$2.18

ACE BANDAGE W/VELCRO 6" WP

Facility

$4.36

Hospital Revenue Code	270
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$2.18
Rate for Payer: SELF PAY	$2.18

Acute and subacute endocarditis with CC*

Facility

$70,400.00

Service Code	MSDRG 289
Min. Negotiated Rate	$28,616.07
Max. Negotiated Rate	$31,795.63
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$31,795.63
Rate for Payer: American Health Plans Medicare Advantage	$31,795.63
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$31,795.63
Rate for Payer: CIGNA Medicare Advantage	$31,795.63
Rate for Payer: HealthChoice Utah Medicare Advantage	$31,795.63
Rate for Payer: Humana Medicare Advantage	$31,795.63
Rate for Payer: Medicare	$31,795.63
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$31,795.63
Rate for Payer: MOLINA MEDICARE	$31,795.63
Rate for Payer: Pacific Source Medicare Advantage	$31,795.63
Rate for Payer: Select Health Medicare Advantage	$31,795.63
Rate for Payer: SELF PAY	$35,200.00
Rate for Payer: Tricare West Military	$28,616.07

Know your out-of-pocket cost for care.

All Charges