Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

RT-Vent Wein Ser L3

Facility

$1,872.00

Hospital Revenue Code	410
Min. Negotiated Rate	$936.00
Max. Negotiated Rate	$936.00
Rate for Payer: SELF PAY	$936.00

SAFE RESPONSE ADULT

Facility

$11.52

Hospital Revenue Code	270
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$5.76
Rate for Payer: SELF PAY	$5.76

SALINE BOTTLE 250ML

Facility

$2.38

Hospital Revenue Code	270
Min. Negotiated Rate	$1.19
Max. Negotiated Rate	$1.19
Rate for Payer: SELF PAY	$1.19

SALINE BOTTLE 250ML WP

Facility

$2.38

Hospital Revenue Code	270
Min. Negotiated Rate	$1.19
Max. Negotiated Rate	$1.19
Rate for Payer: SELF PAY	$1.19

SALINE BULLET 5mL

Facility

$0.18

Hospital Revenue Code	270
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.09
Rate for Payer: SELF PAY	$0.09

SALINE BULLET 5mL WP

Facility

$0.18

Hospital Revenue Code	270
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.09
Rate for Payer: SELF PAY	$0.09

Salivary gland procedures

Facility

$86,400.00

Service Code	MSDRG 139
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

SA NASAL MRSA

Facility

$45.00

Service Code	CPT 87641
Hospital Revenue Code	300
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$22.50
Rate for Payer: SELF PAY	$22.50

SCD 7' TUBING

Facility

$126.30

Hospital Revenue Code	270
Min. Negotiated Rate	$63.15
Max. Negotiated Rate	$63.15
Rate for Payer: SELF PAY	$63.15

SCD KNEE LENGTH SLEEVE LRG

Facility

$83.32

Hospital Revenue Code	270
Min. Negotiated Rate	$41.66
Max. Negotiated Rate	$41.66
Rate for Payer: SELF PAY	$41.66

SCD KNEE LENGTH SLEEVE LRG WP

Facility

$83.32

Hospital Revenue Code	270
Min. Negotiated Rate	$41.66
Max. Negotiated Rate	$41.66
Rate for Payer: SELF PAY	$41.66

SCD KNEE LENGTH SLEEVE MED

Facility

$85.18

Hospital Revenue Code	270
Min. Negotiated Rate	$42.59
Max. Negotiated Rate	$42.59
Rate for Payer: SELF PAY	$42.59

SCD KNEE LENGTH SLEEVE MED WP

Facility

$85.18

Hospital Revenue Code	270
Min. Negotiated Rate	$42.59
Max. Negotiated Rate	$42.59
Rate for Payer: SELF PAY	$42.59

SCD KNEE LENGTH SLEEVE SMALL

Facility

$95.20

Hospital Revenue Code	270
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$47.60
Rate for Payer: SELF PAY	$47.60

SD Wound Vac

Facility

$109.00

Hospital Revenue Code	290
Min. Negotiated Rate	$54.50
Max. Negotiated Rate	$54.50
Rate for Payer: SELF PAY	$54.50

SED RATE (ESR)

Facility

$2.70

Service Code	CPT 85652
Hospital Revenue Code	300
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.35
Rate for Payer: SELF PAY	$1.35

Seizures with MCC

Facility

$86,400.00

Service Code	MSDRG 100
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

Seizures without MCC

Facility

$60,800.00

Service Code	MSDRG 101
Min. Negotiated Rate	$24,374.11
Max. Negotiated Rate	$27,082.35
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$27,082.35
Rate for Payer: American Health Plans Medicare Advantage	$27,082.35
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$27,082.35
Rate for Payer: CIGNA Medicare Advantage	$27,082.35
Rate for Payer: HealthChoice Utah Medicare Advantage	$27,082.35
Rate for Payer: Humana Medicare Advantage	$27,082.35
Rate for Payer: Medicare	$27,082.35
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$27,082.35
Rate for Payer: MOLINA MEDICARE	$27,082.35
Rate for Payer: Pacific Source Medicare Advantage	$27,082.35
Rate for Payer: Select Health Medicare Advantage	$27,082.35
Rate for Payer: SELF PAY	$30,400.00
Rate for Payer: Tricare West Military	$24,374.11

Self Care Home Manage 1

Facility

$51.00

Service Code	CPT 97535
Hospital Revenue Code	420
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$25.50
Rate for Payer: SELF PAY	$25.50

Sensory Integration

Facility

$51.00

Service Code	CPT 97533
Hospital Revenue Code	420
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$25.50
Rate for Payer: SELF PAY	$25.50

Sensura Click Ostomy Barrier 3

Facility

$2.02

Hospital Revenue Code	270
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$1.01
Rate for Payer: SELF PAY	$1.01

SenSura Click Ostomy Barrier 3

Facility

$2.42

Hospital Revenue Code	270
Min. Negotiated Rate	$1.21
Max. Negotiated Rate	$1.21
Rate for Payer: SELF PAY	$1.21

SenSura Click Ostomy Pouch

Facility

$1.92

Hospital Revenue Code	270
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$0.96
Rate for Payer: SELF PAY	$0.96
Rate for Payer: SELF PAY	$0.97

Sensura Click Ostomy Pouch 50m

Facility

$8.96

Hospital Revenue Code	270
Min. Negotiated Rate	$4.48
Max. Negotiated Rate	$4.48
Rate for Payer: SELF PAY	$4.48

SENSURA MIO CLICK 2 3/4

Facility

$0.88

Hospital Revenue Code	270
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.44
Rate for Payer: SELF PAY	$0.44

Know your out-of-pocket cost for care.

All Charges