Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

TAPERED FLEXIBLE IC SIZE 4

Facility

$10.68

Hospital Revenue Code	270
Min. Negotiated Rate	$5.34
Max. Negotiated Rate	$5.34
Rate for Payer: SELF PAY	$5.34

TAPERED FLEXIBLE IC SIZE 6

Facility

$10.66

Hospital Revenue Code	270
Min. Negotiated Rate	$5.33
Max. Negotiated Rate	$5.33
Rate for Payer: SELF PAY	$5.33

TAPERED FLEXIBLE IC SIZE 7

Facility

$10.68

Hospital Revenue Code	270
Min. Negotiated Rate	$5.34
Max. Negotiated Rate	$5.34
Rate for Payer: SELF PAY	$5.34
Rate for Payer: SELF PAY	$5.10

TAPERED FLEXIBLE IC SIZE 8

Facility

$10.68

Hospital Revenue Code	270
Min. Negotiated Rate	$5.34
Max. Negotiated Rate	$5.34
Rate for Payer: SELF PAY	$5.34

TAPE RETENTION 2X10yd HYPAFIX

Facility

$20.36

Hospital Revenue Code	270
Min. Negotiated Rate	$10.18
Max. Negotiated Rate	$10.18
Rate for Payer: SELF PAY	$10.18

TAPE SILICONE KIND REMOVAL

Facility

$7.00

Hospital Revenue Code	270
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$3.50
Rate for Payer: SELF PAY	$3.50

TAPE TRANSPORE 1

Facility

$1.66

Hospital Revenue Code	270
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$0.83
Rate for Payer: SELF PAY	$0.83

TAPE TRANSPORE 1/2

Facility

$0.82

Hospital Revenue Code	270
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.41
Rate for Payer: SELF PAY	$0.41

TAPE TRANSPORE 1/2 WP

Facility

$0.82

Hospital Revenue Code	270
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.41
Rate for Payer: SELF PAY	$0.41

TAPE TRANSPORE 1 WP

Facility

$1.66

Hospital Revenue Code	270
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$0.83
Rate for Payer: SELF PAY	$0.83

TED ANTI EMBOLISM STOCKING MED

Facility

$12.26

Hospital Revenue Code	270
Min. Negotiated Rate	$6.13
Max. Negotiated Rate	$6.13
Rate for Payer: SELF PAY	$6.13

TEGRETOL LEVEL

Facility

$14.57

Service Code	CPT 80156
Hospital Revenue Code	300
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$7.29
Rate for Payer: SELF PAY	$7.29

Teleflex Hiflow

Facility

$27.76

Hospital Revenue Code	290
Min. Negotiated Rate	$13.88
Max. Negotiated Rate	$13.88
Rate for Payer: SELF PAY	$13.88

Telemetry

Facility

$68.86

Hospital Revenue Code	290
Min. Negotiated Rate	$34.43
Max. Negotiated Rate	$34.43
Rate for Payer: SELF PAY	$34.43

TENA STRETCH BRIEF 2XL

Facility

$44.44

Hospital Revenue Code	270
Min. Negotiated Rate	$22.22
Max. Negotiated Rate	$22.22
Rate for Payer: SELF PAY	$22.22

TENA STRETCH BRIEF 2XL WP

Facility

$1.38

Hospital Revenue Code	270
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$0.69
Rate for Payer: SELF PAY	$0.69

TENA STRETCH BRIEF L/XL

Facility

$36.80

Hospital Revenue Code	270
Min. Negotiated Rate	$18.40
Max. Negotiated Rate	$18.40
Rate for Payer: SELF PAY	$18.40

TENA STRETCH BRIEF L/XL WP

Facility

$1.02

Hospital Revenue Code	270
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.51
Rate for Payer: SELF PAY	$0.51

TENA STRETCH BRIEF M/R

Facility

$30.56

Hospital Revenue Code	270
Min. Negotiated Rate	$15.28
Max. Negotiated Rate	$15.28
Rate for Payer: SELF PAY	$15.28

TENA STRETCH BRIEF M/R WP

Facility

$0.84

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

Tendonitis, myositis and bursitis with MCC

Facility

$89,600.00

Service Code	MSDRG 557
Min. Negotiated Rate	$40,674.46
Max. Negotiated Rate	$45,193.85
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$45,193.85
Rate for Payer: American Health Plans Medicare Advantage	$45,193.85
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$45,193.85
Rate for Payer: CIGNA Medicare Advantage	$45,193.85
Rate for Payer: HealthChoice Utah Medicare Advantage	$45,193.85
Rate for Payer: Humana Medicare Advantage	$45,193.85
Rate for Payer: Medicare	$45,193.85
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$45,193.85
Rate for Payer: MOLINA MEDICARE	$45,193.85
Rate for Payer: Pacific Source Medicare Advantage	$45,193.85
Rate for Payer: Select Health Medicare Advantage	$45,193.85
Rate for Payer: SELF PAY	$44,800.00
Rate for Payer: Tricare West Military	$40,674.46

Tendonitis, myositis and bursitis without MCC

Facility

$80,000.00

Service Code	MSDRG 558
Min. Negotiated Rate	$31,490.95
Max. Negotiated Rate	$34,989.94
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$34,989.94
Rate for Payer: American Health Plans Medicare Advantage	$34,989.94
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$34,989.94
Rate for Payer: CIGNA Medicare Advantage	$34,989.94
Rate for Payer: HealthChoice Utah Medicare Advantage	$34,989.94
Rate for Payer: Humana Medicare Advantage	$34,989.94
Rate for Payer: Medicare	$34,989.94
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$34,989.94
Rate for Payer: MOLINA MEDICARE	$34,989.94
Rate for Payer: Pacific Source Medicare Advantage	$34,989.94
Rate for Payer: Select Health Medicare Advantage	$34,989.94
Rate for Payer: SELF PAY	$40,000.00
Rate for Payer: Tricare West Military	$31,490.95

Testes procedures with CC/MCC

Facility

$112,000.00

Service Code	MSDRG 711
Min. Negotiated Rate	$62,443.10
Max. Negotiated Rate	$69,381.22
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$69,381.22
Rate for Payer: American Health Plans Medicare Advantage	$69,381.22
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$69,381.22
Rate for Payer: CIGNA Medicare Advantage	$69,381.22
Rate for Payer: HealthChoice Utah Medicare Advantage	$69,381.22
Rate for Payer: Humana Medicare Advantage	$69,381.22
Rate for Payer: Medicare	$69,381.22
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$69,381.22
Rate for Payer: MOLINA MEDICARE	$69,381.22
Rate for Payer: Pacific Source Medicare Advantage	$69,381.22
Rate for Payer: Select Health Medicare Advantage	$69,381.22
Rate for Payer: SELF PAY	$56,000.00
Rate for Payer: Tricare West Military	$62,443.10

Testes procedures without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 712
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

Test Lung

Facility

$19.64

Hospital Revenue Code	290
Min. Negotiated Rate	$9.82
Max. Negotiated Rate	$9.82
Rate for Payer: SELF PAY	$9.82

Know your out-of-pocket cost for care.

All Charges