Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

GAUZE 2X2 8PLY WP

Facility

$0.04

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

GAUZE 4X4 12PLY

Facility

$0.14

Hospital Revenue Code	270
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.07
Rate for Payer: SELF PAY	$0.07

GAUZE 4X4 12PLY WP

Facility

$0.14

Hospital Revenue Code	270
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.07
Rate for Payer: SELF PAY	$0.07

GAUZE CONFORM 1"X75"

Facility

$1.00

Hospital Revenue Code	270
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: SELF PAY	$0.50

GAUZE CONFORM 1"X75" WP

Facility

$1.00

Hospital Revenue Code	270
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: SELF PAY	$0.50

GAUZE DRAIN SPONGE 4X4

Facility

$0.12

Hospital Revenue Code	270
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.06
Rate for Payer: SELF PAY	$0.06

GAUZE DRAIN SPONGE 4X4 WP

Facility

$0.12

Hospital Revenue Code	270
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.06
Rate for Payer: SELF PAY	$0.06

GAUZE IV SPONGE 2X2

Facility

$0.10

Hospital Revenue Code	270
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.05
Rate for Payer: SELF PAY	$0.05

GAUZE IV SPONGE 2X2 WP

Facility

$0.10

Hospital Revenue Code	270
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.05
Rate for Payer: SELF PAY	$0.05

GAUZE KERLIX ST 4.5"X4.1yd

Facility

$0.92

Hospital Revenue Code	270
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.46
Rate for Payer: SELF PAY	$0.46

GAUZE KERLIX ST 4.5"X4.1yd WP

Facility

$0.92

Hospital Revenue Code	270
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.46
Rate for Payer: SELF PAY	$0.46

GENTAMYCIN PEAK

Facility

$125.00

Service Code	CPT 80170
Hospital Revenue Code	300
Min. Negotiated Rate	$62.50
Max. Negotiated Rate	$62.50
Rate for Payer: SELF PAY	$62.50

GENTAMYCIN TROUGH

Facility

$125.00

Service Code	CPT 80170
Hospital Revenue Code	300
Min. Negotiated Rate	$62.50
Max. Negotiated Rate	$62.50
Rate for Payer: SELF PAY	$62.50

GLOVE NITRILE LARGE

Facility

$48.10

Hospital Revenue Code	270
Min. Negotiated Rate	$24.05
Max. Negotiated Rate	$24.05
Rate for Payer: SELF PAY	$24.05

GLOVE NITRILE LARGE WP

Facility

$48.10

Hospital Revenue Code	270
Min. Negotiated Rate	$24.05
Max. Negotiated Rate	$24.05
Rate for Payer: SELF PAY	$24.05

GLOVE NITRILE MEDIUM

Facility

$48.10

Hospital Revenue Code	270
Min. Negotiated Rate	$24.05
Max. Negotiated Rate	$24.05
Rate for Payer: SELF PAY	$24.05

GLOVE NITRILE MEDIUM WP

Facility

$48.10

Hospital Revenue Code	270
Min. Negotiated Rate	$24.05
Max. Negotiated Rate	$24.05
Rate for Payer: SELF PAY	$24.05

GLOVE NITRILE SMALL

Facility

$48.10

Hospital Revenue Code	270
Min. Negotiated Rate	$24.05
Max. Negotiated Rate	$24.05
Rate for Payer: SELF PAY	$24.05

GLOVE NITRILE SMALL WP

Facility

$48.10

Hospital Revenue Code	270
Min. Negotiated Rate	$24.05
Max. Negotiated Rate	$24.05
Rate for Payer: SELF PAY	$24.05

GLOVE NITRILE XL

Facility

$48.10

Hospital Revenue Code	270
Min. Negotiated Rate	$24.05
Max. Negotiated Rate	$24.05
Rate for Payer: SELF PAY	$24.05

GLOVE NITRILE XL WP

Facility

$48.10

Hospital Revenue Code	270
Min. Negotiated Rate	$24.05
Max. Negotiated Rate	$24.05
Rate for Payer: SELF PAY	$24.05

GLOVE STERILE LARGE

Facility

$0.84

Hospital Revenue Code	270
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.42
Rate for Payer: SELF PAY	$0.42

Glove Sterile Large WP

Facility

$0.84

Hospital Revenue Code	270
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.42
Rate for Payer: SELF PAY	$0.42

GLOVE STERILE MEDIUM

Facility

$1.28

Hospital Revenue Code	270
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.64
Rate for Payer: SELF PAY	$0.64

GLOVE STERILE MEDIUM WP

Facility

$1.28

Hospital Revenue Code	270
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.64
Rate for Payer: SELF PAY	$0.64

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All Charges