Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

OT Re-Eval

Facility

$76.00

Service Code	CPT 97004
Hospital Revenue Code	430
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$38.00
Rate for Payer: SELF PAY	$38.00

OT Re-Evaluation

Facility

$76.00

Hospital Revenue Code	430
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$38.00
Rate for Payer: SELF PAY	$38.00

Overlay

Facility

$20.50

Hospital Revenue Code	290
Min. Negotiated Rate	$10.25
Max. Negotiated Rate	$10.25
Rate for Payer: SELF PAY	$10.25

OXYGEN MASK MEDIUM CONCENTRATI

Facility

$0.98

Hospital Revenue Code	270
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$0.49
Rate for Payer: SELF PAY	$0.49

OXYGEN MASK PARTIAL REBREATHER

Facility

$2.76

Hospital Revenue Code	270
Min. Negotiated Rate	$1.38
Max. Negotiated Rate	$1.38
Rate for Payer: SELF PAY	$1.38

OXYGEN MASK PEDIATRIC

Facility

$2.26

Hospital Revenue Code	270
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.13
Rate for Payer: SELF PAY	$1.13

OXYGEN MASK REBREATH W/7' TUBI

Facility

$2.44

Hospital Revenue Code	270
Min. Negotiated Rate	$1.22
Max. Negotiated Rate	$1.22
Rate for Payer: SELF PAY	$1.22

OXYGEN O-RING

Facility

$0.86

Hospital Revenue Code	270
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.43
Rate for Payer: SELF PAY	$0.43

OXYGEN O-RING WP

Facility

$0.86

Hospital Revenue Code	270
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.43
Rate for Payer: SELF PAY	$0.43

OXYGEN STEM

Facility

$1.20

Hospital Revenue Code	270
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: SELF PAY	$0.60

OXYGEN STEM WP

Facility

$1.20

Hospital Revenue Code	270
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: SELF PAY	$0.60

OXYGEN TUBING 25'

Facility

$2.74

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

OXYGEN TUBING 25' 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

OXYGEN TUBING 7'

Facility

$0.56

Hospital Revenue Code	270
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.28
Rate for Payer: SELF PAY	$0.28

OXYGEN TUBING 7' WP

Facility

$0.56

Hospital Revenue Code	270
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.28
Rate for Payer: SELF PAY	$0.28

OXYGEN TUBING CONNECTORS (5in1

Facility

$0.20

Hospital Revenue Code	270
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.10
Rate for Payer: SELF PAY	$0.10

OXYMASK ADULT WP

Facility

$11.72

Hospital Revenue Code	270
Min. Negotiated Rate	$5.86
Max. Negotiated Rate	$5.86
Rate for Payer: SELF PAY	$5.86

OXYMIZER CANNULA MUSTACHE

Facility

$30.16

Hospital Revenue Code	270
Min. Negotiated Rate	$15.08
Max. Negotiated Rate	$15.08
Rate for Payer: SELF PAY	$15.08

OXYMIZER CANNULA MUSTACHE WP

Facility

$30.16

Hospital Revenue Code	270
Min. Negotiated Rate	$15.08
Max. Negotiated Rate	$15.08
Rate for Payer: SELF PAY	$15.08

OXYMIZER CANNULA PENDANT

Facility

$30.22

Hospital Revenue Code	270
Min. Negotiated Rate	$15.11
Max. Negotiated Rate	$15.11
Rate for Payer: SELF PAY	$15.11

OXYMIZER CANNULA PENDANT WP

Facility

$30.22

Hospital Revenue Code	270
Min. Negotiated Rate	$15.11
Max. Negotiated Rate	$15.11
Rate for Payer: SELF PAY	$15.11

PACKING STRIP IODOFORM

Facility

$3.78

Hospital Revenue Code	270
Min. Negotiated Rate	$1.89
Max. Negotiated Rate	$1.89
Rate for Payer: SELF PAY	$1.89

PACKING STRIP IODOFORM WP

Facility

$3.78

Hospital Revenue Code	270
Min. Negotiated Rate	$1.89
Max. Negotiated Rate	$1.89
Rate for Payer: SELF PAY	$1.89

PACKING STRIP PLAIN 1/2 IN

Facility

$6.04

Hospital Revenue Code	270
Min. Negotiated Rate	$3.02
Max. Negotiated Rate	$3.02
Rate for Payer: SELF PAY	$3.02

PACKING STRIP PLAIN 1/4 IN.

Facility

$3.10

Hospital Revenue Code	270
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$1.55
Rate for Payer: SELF PAY	$1.55

Know your out-of-pocket cost for care.

All Charges