Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

Pulmo Aide

Facility

$3.22

Hospital Revenue Code	290
Min. Negotiated Rate	$1.61
Max. Negotiated Rate	$1.61
Rate for Payer: SELF PAY	$1.61

Pulmonary edema and respiratory failure

Facility

$67,200.00

Service Code	MSDRG 189
Min. Negotiated Rate	$37,859.90
Max. Negotiated Rate	$42,066.55
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$42,066.55
Rate for Payer: American Health Plans Medicare Advantage	$42,066.55
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$42,066.55
Rate for Payer: CIGNA Medicare Advantage	$42,066.55
Rate for Payer: HealthChoice Utah Medicare Advantage	$42,066.55
Rate for Payer: Humana Medicare Advantage	$42,066.55
Rate for Payer: Medicare	$42,066.55
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$42,066.55
Rate for Payer: MOLINA MEDICARE	$42,066.55
Rate for Payer: Pacific Source Medicare Advantage	$42,066.55
Rate for Payer: Select Health Medicare Advantage	$42,066.55
Rate for Payer: SELF PAY	$33,600.00
Rate for Payer: Tricare West Military	$37,859.90

Pulmonary embolism with MCC or acute cor pulmonale

Facility

$70,400.00

Service Code	MSDRG 175
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

Pulmonary embolism without MCC

Facility

$51,200.00

Service Code	MSDRG 176
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

Pulse Oximeter/Day

Facility

$56.00

Hospital Revenue Code	290
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$28.00
Rate for Payer: SELF PAY	$28.00

PUREWICK SYSTEM WP

Facility

$45.98

Hospital Revenue Code	270
Min. Negotiated Rate	$22.99
Max. Negotiated Rate	$22.99
Rate for Payer: SELF PAY	$22.99

PURITAN BENNETT VENT FILTER WP

Facility

$28.68

Hospital Revenue Code	270
Min. Negotiated Rate	$14.34
Max. Negotiated Rate	$14.34
Rate for Payer: SELF PAY	$14.34

Puritan Bennet Ventilator

Facility

$102.60

Hospital Revenue Code	290
Min. Negotiated Rate	$51.30
Max. Negotiated Rate	$51.30
Rate for Payer: SELF PAY	$51.30

QUANTIFERON TB GOLD PLUS

Facility

$42.00

Service Code	CPT 86480
Hospital Revenue Code	300
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$21.00
Rate for Payer: SELF PAY	$21.00

Rad7 w/Docking Station

Facility

$1.00

Hospital Revenue Code	290
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: SELF PAY	$0.50

Rad7 w/Root

Facility

$1.00

Hospital Revenue Code	290
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: SELF PAY	$0.50

Radiologic examination, gastrointestinal tract, upper; with or without delayed images, without KUB

Facility

$149.26

Service Code	CPT 74240 TC
Hospital Revenue Code	320
Min. Negotiated Rate	$74.63
Max. Negotiated Rate	$74.63
Rate for Payer: SELF PAY	$74.63

Radiologic examination, mandible; partial, less than 4 views

Facility

$51.34

Service Code	CPT 70100 TC
Hospital Revenue Code	320
Min. Negotiated Rate	$25.67
Max. Negotiated Rate	$25.67
Rate for Payer: SELF PAY	$25.67

Radiologic examination; pharynx or larynx, including fluoroscopy and/or magnification technique

Facility

$137.94

Service Code	CPT 70370 TC
Hospital Revenue Code	320
Min. Negotiated Rate	$68.97
Max. Negotiated Rate	$68.97
Rate for Payer: SELF PAY	$68.97

Radiologic examination, spine, cervical; 2 or 3 views

Facility

$50.00

Service Code	CPT 72040 TC
Hospital Revenue Code	320
Min. Negotiated Rate	$25.00
Max. Negotiated Rate	$25.00
Rate for Payer: SELF PAY	$25.00

Radiologic examination, teeth; partial examination, less than full mouth

Facility

$29.33

Service Code	CPT 70310 TC
Hospital Revenue Code	320
Min. Negotiated Rate	$14.66
Max. Negotiated Rate	$14.66
Rate for Payer: SELF PAY	$14.66

Radiotherapy

Facility

$51,200.00

Service Code	MSDRG 849
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

RAZOR TWIN BLADE DISP

Facility

$0.26

Hospital Revenue Code	270
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.13
Rate for Payer: SELF PAY	$0.13

RAZOR TWIN BLADE DISP WP

Facility

$0.26

Hospital Revenue Code	270
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.13
Rate for Payer: SELF PAY	$0.13

RBC

Facility

$3.02

Service Code	CPT 85041
Hospital Revenue Code	300
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$1.51
Rate for Payer: SELF PAY	$1.51

RCI Tubing Adapters

Facility

$0.66

Hospital Revenue Code	270
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.33
Rate for Payer: SELF PAY	$0.33

RD SP02 SENSOR

Facility

$27.26

Hospital Revenue Code	270
Min. Negotiated Rate	$13.63
Max. Negotiated Rate	$13.63
Rate for Payer: SELF PAY	$13.63

READY BATH WIPES

Facility

$2.82

Hospital Revenue Code	270
Min. Negotiated Rate	$1.41
Max. Negotiated Rate	$1.41
Rate for Payer: SELF PAY	$1.41

READY BATH WIPES WP

Facility

$2.82

Hospital Revenue Code	270
Min. Negotiated Rate	$1.41
Max. Negotiated Rate	$1.41
Rate for Payer: SELF PAY	$1.41

READY PREP CHG

Facility

$3.76

Hospital Revenue Code	270
Min. Negotiated Rate	$1.88
Max. Negotiated Rate	$1.88
Rate for Payer: SELF PAY	$1.88

Know your out-of-pocket cost for care.

All Charges