Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

TONGUE DEPRESSOR STERILE

Facility

$0.02

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

TONGUE SCRAPER

Facility

$4.20

Hospital Revenue Code	270
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$2.10
Rate for Payer: SELF PAY	$2.10

TOOTHBRUSH

Facility

$0.52

Hospital Revenue Code	270
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.26
Rate for Payer: SELF PAY	$0.26

TOOTHBRUSH WP

Facility

$0.52

Hospital Revenue Code	270
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.26
Rate for Payer: SELF PAY	$0.26

TOOTHETTE

Facility

$4.56

Hospital Revenue Code	270
Min. Negotiated Rate	$2.28
Max. Negotiated Rate	$2.28
Rate for Payer: SELF PAY	$2.28

Toothette 3rd floor

Facility

$0.18

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

TOOTHETTE WP

Facility

$4.56

Hospital Revenue Code	270
Min. Negotiated Rate	$2.28
Max. Negotiated Rate	$2.28
Rate for Payer: SELF PAY	$2.28

TOOTHPASTE

Facility

$1.86

Hospital Revenue Code	270
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$0.93
Rate for Payer: SELF PAY	$0.93

TOOTHPASTE WP

Facility

$1.86

Hospital Revenue Code	270
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$0.93
Rate for Payer: SELF PAY	$0.93

Trach Anchor

Facility

$30.44

Hospital Revenue Code	270
Min. Negotiated Rate	$15.22
Max. Negotiated Rate	$15.22
Rate for Payer: SELF PAY	$15.22

TRACH ANTI-DISCONNECT

Facility

$6.52

Hospital Revenue Code	270
Min. Negotiated Rate	$3.26
Max. Negotiated Rate	$3.26
Rate for Payer: SELF PAY	$3.26

TRACH CARE KIT

Facility

$3.38

Hospital Revenue Code	270
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$1.69
Rate for Payer: SELF PAY	$1.69

TRACH CARE KIT WP

Facility

$3.38

Hospital Revenue Code	270
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$1.69
Rate for Payer: SELF PAY	$1.69

Tracheostomy for face, mouth and neck diagnoses or laryngectomy with CC

Facility

$112,000.00

Service Code	MSDRG 12
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

Tracheostomy for face, mouth and neck diagnoses or laryngectomy with MCC

Facility

$112,000.00

Service Code	MSDRG 11
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

Tracheostomy for face, mouth and neck diagnoses or laryngectomy without CC/MCC

Facility

$112,000.00

Service Code	MSDRG 13
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

Tracheostomy with MV >96 hours or principal diagnosis except face, mouth and neck without major O.R. procedures

Facility

$140,800.00

Service Code	MSDRG 4
Min. Negotiated Rate	$116,185.18
Max. Negotiated Rate	$129,094.64
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$129,094.64
Rate for Payer: American Health Plans Medicare Advantage	$129,094.64
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$129,094.64
Rate for Payer: CIGNA Medicare Advantage	$129,094.64
Rate for Payer: HealthChoice Utah Medicare Advantage	$129,094.64
Rate for Payer: Humana Medicare Advantage	$129,094.64
Rate for Payer: Medicare	$129,094.64
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$129,094.64
Rate for Payer: MOLINA MEDICARE	$129,094.64
Rate for Payer: Pacific Source Medicare Advantage	$129,094.64
Rate for Payer: Select Health Medicare Advantage	$129,094.64
Rate for Payer: SELF PAY	$70,400.00
Rate for Payer: Tricare West Military	$116,185.18

TRACH GUARD

Facility

$14.66

Hospital Revenue Code	270
Min. Negotiated Rate	$7.33
Max. Negotiated Rate	$7.33
Rate for Payer: SELF PAY	$7.33

TRACH GUARD WP

Facility

$14.66

Hospital Revenue Code	270
Min. Negotiated Rate	$7.33
Max. Negotiated Rate	$7.33
Rate for Payer: SELF PAY	$7.33

TRACH MASK ADULT

Facility

$1.80

Hospital Revenue Code	270
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$0.90
Rate for Payer: SELF PAY	$0.90

TRACH MASK ADULT WP

Facility

$1.80

Hospital Revenue Code	270
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$0.90
Rate for Payer: SELF PAY	$0.90

TRACH MASK PEDATRIC

Facility

$2.20

Hospital Revenue Code	270
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.10
Rate for Payer: SELF PAY	$1.10

TRACH PLUG CLIP RED

Facility

$1.10

Hospital Revenue Code	270
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.55
Rate for Payer: SELF PAY	$0.55

TRACH PLUG WHITE

Facility

$13.48

Hospital Revenue Code	270
Min. Negotiated Rate	$6.74
Max. Negotiated Rate	$6.74
Rate for Payer: SELF PAY	$6.74

TRACH PLUG WHITE WP

Facility

$13.48

Hospital Revenue Code	270
Min. Negotiated Rate	$6.74
Max. Negotiated Rate	$6.74
Rate for Payer: SELF PAY	$6.74

Know your out-of-pocket cost for care.

All Charges