Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

STICK MANICURE

Facility

$0.02

Hospital Revenue Code	270
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: SELF PAY	$0.01

STICK MANICURE WP

Facility

$0.02

Hospital Revenue Code	270
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: SELF PAY	$0.01

Stomach, esophageal and duodenal procedures with CC

Facility

$64,000.00

Service Code	MSDRG 327
Min. Negotiated Rate	$27,594.78
Max. Negotiated Rate	$30,660.87
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$30,660.87
Rate for Payer: American Health Plans Medicare Advantage	$30,660.87
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$30,660.87
Rate for Payer: CIGNA Medicare Advantage	$30,660.87
Rate for Payer: HealthChoice Utah Medicare Advantage	$30,660.87
Rate for Payer: Humana Medicare Advantage	$30,660.87
Rate for Payer: Medicare	$30,660.87
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$30,660.87
Rate for Payer: MOLINA MEDICARE	$30,660.87
Rate for Payer: Pacific Source Medicare Advantage	$30,660.87
Rate for Payer: Select Health Medicare Advantage	$30,660.87
Rate for Payer: SELF PAY	$32,000.00
Rate for Payer: Tricare West Military	$27,594.78

Stomach, esophageal and duodenal procedures with MCC

Facility

$86,400.00

Service Code	MSDRG 326
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

Stomach, esophageal and duodenal procedures without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 328
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

STOOL CULTURE

Facility

$9.44

Service Code	CPT 87046
Hospital Revenue Code	300
Min. Negotiated Rate	$4.72
Max. Negotiated Rate	$4.72
Rate for Payer: SELF PAY	$4.72

STOOL OCCULT

Facility

$15.92

Service Code	CPT 82274
Hospital Revenue Code	300
Min. Negotiated Rate	$7.96
Max. Negotiated Rate	$7.96
Rate for Payer: SELF PAY	$7.96

Straight Adapter Airway Adult

Facility

$27.28

Hospital Revenue Code	270
Min. Negotiated Rate	$13.64
Max. Negotiated Rate	$13.64
Rate for Payer: SELF PAY	$13.64

STRAIGHT ADAPTER M/F ENDS

Facility

$2.28

Hospital Revenue Code	270
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$1.14
Rate for Payer: SELF PAY	$1.14

STRAIGHT ADAPTER M/F ENDS WP

Facility

$2.28

Hospital Revenue Code	270
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$1.14
Rate for Payer: SELF PAY	$1.14

Strapping - Knee

Facility

$72.94

Service Code	CPT 29530
Hospital Revenue Code	430
Min. Negotiated Rate	$36.47
Max. Negotiated Rate	$36.47
Rate for Payer: SELF PAY	$36.47

STREP RAID BY PCR

Facility

$111.00

Service Code	CPT 87651
Hospital Revenue Code	300
Min. Negotiated Rate	$55.50
Max. Negotiated Rate	$55.50
Rate for Payer: SELF PAY	$55.50

STRONG-HOLD CHILD

Facility

$5.12

Hospital Revenue Code	270
Min. Negotiated Rate	$2.56
Max. Negotiated Rate	$2.56
Rate for Payer: SELF PAY	$2.56

SUCTION CANISTER 800cc TRAVEL

Facility

$5.08

Hospital Revenue Code	270
Min. Negotiated Rate	$2.54
Max. Negotiated Rate	$2.54
Rate for Payer: SELF PAY	$2.54

SUCTION CANISTER LINER/LID 150

Facility

$2.88

Hospital Revenue Code	270
Min. Negotiated Rate	$1.44
Max. Negotiated Rate	$1.44
Rate for Payer: SELF PAY	$1.44

SUCTION KIT 10FR

Facility

$1.18

Hospital Revenue Code	270
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.59
Rate for Payer: SELF PAY	$0.59

SUCTION KIT 12FR

Facility

$1.06

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

SUCTION KIT 12FRWP

Facility

$1.06

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

SUCTION KIT 14FR

Facility

$0.84

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

SUCTION KIT 14FR 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

SUCTION KIT 5/6FR

Facility

$1.12

Hospital Revenue Code	270
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.56
Rate for Payer: SELF PAY	$0.56

SUCTION KIT 8FR

Facility

$1.18

Hospital Revenue Code	270
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.59
Rate for Payer: SELF PAY	$0.59

SUCTION PROBE KIT (ORAL)

Facility

$4.46

Hospital Revenue Code	270
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$2.23
Rate for Payer: SELF PAY	$2.23

SUCTION PROBE KIT (ORAL) WP

Facility

$4.46

Hospital Revenue Code	270
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$2.23
Rate for Payer: SELF PAY	$2.23

Suction Pump/Day

Facility

$8.00

Hospital Revenue Code	290
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$4.00
Rate for Payer: SELF PAY	$4.00

Know your out-of-pocket cost for care.

All Charges