Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

SLIPPER NONSKID`LARGE

Facility

$1.28

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

SLIPPER NONSKID LARGE 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

SLIPPER NONSKID 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

SLIPPER NONSKID XL

Facility

$1.28

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

SLIPPER NONSKID XL 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

SLIPPER SMALL

Facility

$1.90

Hospital Revenue Code	270
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$0.95
Rate for Payer: SELF PAY	$0.95

SMALL SPU WRAP VEST

Facility

$135.20

Hospital Revenue Code	270
Min. Negotiated Rate	$67.60
Max. Negotiated Rate	$67.60
Rate for Payer: SELF PAY	$67.60

SMALL SUPER BRIEF

Facility

$7.56

Hospital Revenue Code	270
Min. Negotiated Rate	$3.78
Max. Negotiated Rate	$3.78
Rate for Payer: SELF PAY	$3.78

Soft tissue procedures with CC

Facility

$86,400.00

Service Code	MSDRG 501
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

Soft tissue procedures with MCC

Facility

$108,800.00

Service Code	MSDRG 500
Min. Negotiated Rate	$55,326.28
Max. Negotiated Rate	$61,473.64
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$61,473.64
Rate for Payer: American Health Plans Medicare Advantage	$61,473.64
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$61,473.64
Rate for Payer: CIGNA Medicare Advantage	$61,473.64
Rate for Payer: HealthChoice Utah Medicare Advantage	$61,473.64
Rate for Payer: Humana Medicare Advantage	$61,473.64
Rate for Payer: Medicare	$61,473.64
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$61,473.64
Rate for Payer: MOLINA MEDICARE	$61,473.64
Rate for Payer: Pacific Source Medicare Advantage	$61,473.64
Rate for Payer: Select Health Medicare Advantage	$61,473.64
Rate for Payer: SELF PAY	$54,400.00
Rate for Payer: Tricare West Military	$55,326.28

Soft tissue procedures without CC/MCC

Facility

$67,200.00

Service Code	MSDRG 502
Min. Negotiated Rate	$35,266.48
Max. Negotiated Rate	$39,184.98
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$39,184.98
Rate for Payer: American Health Plans Medicare Advantage	$39,184.98
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$39,184.98
Rate for Payer: CIGNA Medicare Advantage	$39,184.98
Rate for Payer: HealthChoice Utah Medicare Advantage	$39,184.98
Rate for Payer: Humana Medicare Advantage	$39,184.98
Rate for Payer: Medicare	$39,184.98
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$39,184.98
Rate for Payer: MOLINA MEDICARE	$39,184.98
Rate for Payer: Pacific Source Medicare Advantage	$39,184.98
Rate for Payer: Select Health Medicare Advantage	$39,184.98
Rate for Payer: SELF PAY	$33,600.00
Rate for Payer: Tricare West Military	$35,266.48

SORBAVIEW SHIELD IV CONTOUR

Facility

$6.50

Hospital Revenue Code	270
Min. Negotiated Rate	$3.25
Max. Negotiated Rate	$3.25
Rate for Payer: SELF PAY	$3.25

SORBAVIEW SHIELD IV CONTOUR WP

Facility

$6.50

Hospital Revenue Code	270
Min. Negotiated Rate	$3.25
Max. Negotiated Rate	$3.25
Rate for Payer: SELF PAY	$3.25

SP02 SENSOR

Facility

$27.46

Hospital Revenue Code	270
Min. Negotiated Rate	$13.73
Max. Negotiated Rate	$13.73
Rate for Payer: SELF PAY	$13.73

SP02 SENSOR WP

Facility

$27.46

Hospital Revenue Code	270
Min. Negotiated Rate	$13.73
Max. Negotiated Rate	$13.73
Rate for Payer: SELF PAY	$13.73

SPEAKING VALVE-TRACH SHILEY

Facility

$156.44

Hospital Revenue Code	270
Min. Negotiated Rate	$78.22
Max. Negotiated Rate	$78.22
Rate for Payer: SELF PAY	$78.22

SPECIMEN CONTAINER 4oz

Facility

$0.34

Hospital Revenue Code	270
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.17
Rate for Payer: SELF PAY	$0.17

SPECIMEN CONTAINER 4oz WP

Facility

$0.34

Hospital Revenue Code	270
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.17
Rate for Payer: SELF PAY	$0.17

SPECIMEN HAT

Facility

$1.06

Hospital Revenue Code	270
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.53
Rate for Payer: SELF PAY	$0.53

SPECIMEN HAT WP

Facility

$1.06

Hospital Revenue Code	270
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.53
Rate for Payer: SELF PAY	$0.53

SPECIMEN MUCUS TRAP

Facility

$3.06

Hospital Revenue Code	270
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$1.53
Rate for Payer: SELF PAY	$1.53

SPECIMEN MUCUS TRAP WP

Facility

$3.06

Hospital Revenue Code	270
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$1.53
Rate for Payer: SELF PAY	$1.53

Speech Treatment - 1 Uni

Facility

$153.94

Service Code	CPT 92507
Hospital Revenue Code	440
Min. Negotiated Rate	$76.97
Max. Negotiated Rate	$76.97
Rate for Payer: SELF PAY	$76.97

SPIKE SCREW SAFETY W/BAG KANGA

Facility

$8.28

Hospital Revenue Code	270
Min. Negotiated Rate	$4.14
Max. Negotiated Rate	$4.14
Rate for Payer: SELF PAY	$4.14

Spinal disorders and injuries with CC/MCC*

Facility

$124,800.00

Service Code	MSDRG 52
Min. Negotiated Rate	$43,585.52
Max. Negotiated Rate	$48,428.36
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$48,428.36
Rate for Payer: American Health Plans Medicare Advantage	$48,428.36
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$48,428.36
Rate for Payer: CIGNA Medicare Advantage	$48,428.36
Rate for Payer: HealthChoice Utah Medicare Advantage	$48,428.36
Rate for Payer: Humana Medicare Advantage	$48,428.36
Rate for Payer: Medicare	$48,428.36
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$48,428.36
Rate for Payer: MOLINA MEDICARE	$48,428.36
Rate for Payer: Pacific Source Medicare Advantage	$48,428.36
Rate for Payer: Select Health Medicare Advantage	$48,428.36
Rate for Payer: SELF PAY	$62,400.00
Rate for Payer: Tricare West Military	$43,585.52

Know your out-of-pocket cost for care.

All Charges