Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

VITAL AF 8OZ CARTON WP

Facility

$6.54

Hospital Revenue Code	270
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$3.27
Rate for Payer: SELF PAY	$3.27

VITAL HP

Facility

$33.16

Hospital Revenue Code	270
Min. Negotiated Rate	$16.58
Max. Negotiated Rate	$16.58
Rate for Payer: SELF PAY	$16.58

VITAL HP WP

Facility

$30.12

Hospital Revenue Code	270
Min. Negotiated Rate	$15.06
Max. Negotiated Rate	$15.06
Rate for Payer: SELF PAY	$15.06

VITAMIN B12

Facility

$12.34

Service Code	CPT 82607
Hospital Revenue Code	300
Min. Negotiated Rate	$6.17
Max. Negotiated Rate	$6.17
Rate for Payer: SELF PAY	$6.17

VITAMIN D 25 DIHYDROXY

Facility

$75.99

Service Code	CPT 82265 52
Hospital Revenue Code	300
Min. Negotiated Rate	$37.99
Max. Negotiated Rate	$37.99
Rate for Payer: SELF PAY	$37.99

VITAMIN D 25 HYDROXY

Facility

$58.00

Service Code	CPT 82306
Hospital Revenue Code	300
Min. Negotiated Rate	$29.00
Max. Negotiated Rate	$29.00
Rate for Payer: SELF PAY	$29.00

VOCSN CIRCUIT, ADULT, ACTIVE,

Facility

$75.50

Hospital Revenue Code	270
Min. Negotiated Rate	$37.75
Max. Negotiated Rate	$37.75
Rate for Payer: SELF PAY	$37.75

Volume Metric Measuremn 1 unit

Facility

$40.32

Service Code	CPT 97750
Hospital Revenue Code	430
Min. Negotiated Rate	$20.16
Max. Negotiated Rate	$20.16
Rate for Payer: SELF PAY	$20.16

WASH BASIN

Facility

$1.16

Hospital Revenue Code	270
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.58
Rate for Payer: SELF PAY	$0.58

WASH BASIN WP

Facility

$1.16

Hospital Revenue Code	270
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.58
Rate for Payer: SELF PAY	$0.58

WATER PITCHER

Facility

$1.08

Hospital Revenue Code	270
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.54
Rate for Payer: SELF PAY	$0.54

WATER PITCHER LINER 28OZ

Facility

$0.38

Hospital Revenue Code	270
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.19
Rate for Payer: SELF PAY	$0.19

WATER PITCHER LINER 28OZ WP

Facility

$0.38

Hospital Revenue Code	270
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.19
Rate for Payer: SELF PAY	$0.19

WATER PITCHER WP

Facility

$1.08

Hospital Revenue Code	270
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.54
Rate for Payer: SELF PAY	$0.54

WATER SEAL CHEST DRAIN WP

Facility

$129.20

Hospital Revenue Code	270
Min. Negotiated Rate	$64.60
Max. Negotiated Rate	$64.60
Rate for Payer: SELF PAY	$64.60

WBC

Facility

$2.90

Service Code	CPT 85048
Hospital Revenue Code	300
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$1.45
Rate for Payer: SELF PAY	$1.45

Wheelchair Training (15"

Facility

$45.00

Service Code	CPT 97542
Hospital Revenue Code	430
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$22.50
Rate for Payer: SELF PAY	$22.50

Wheelchair Training 1 un

Facility

$45.00

Service Code	CPT 97542
Hospital Revenue Code	420
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$22.50
Rate for Payer: SELF PAY	$22.50

WHISPER SWIVEL EXHALATION PORT

Facility

$48.42

Hospital Revenue Code	270
Min. Negotiated Rate	$24.21
Max. Negotiated Rate	$24.21
Rate for Payer: SELF PAY	$24.21

WIPES

Facility

$2.88

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

WIPES WP

Facility

$2.88

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

WOUND CULTURE

Facility

$39.00

Service Code	CPT 87070
Hospital Revenue Code	300
Min. Negotiated Rate	$19.50
Max. Negotiated Rate	$19.50
Rate for Payer: SELF PAY	$19.50

Wound debridement and skin graft except hand for musculoskeletal and connective tissue disorders with CC

Facility

$96,000.00

Service Code	MSDRG 464
Min. Negotiated Rate	$42,837.65
Max. Negotiated Rate	$47,597.39
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$47,597.39
Rate for Payer: American Health Plans Medicare Advantage	$47,597.39
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$47,597.39
Rate for Payer: CIGNA Medicare Advantage	$47,597.39
Rate for Payer: HealthChoice Utah Medicare Advantage	$47,597.39
Rate for Payer: Humana Medicare Advantage	$47,597.39
Rate for Payer: Medicare	$47,597.39
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$47,597.39
Rate for Payer: MOLINA MEDICARE	$47,597.39
Rate for Payer: Pacific Source Medicare Advantage	$47,597.39
Rate for Payer: Select Health Medicare Advantage	$47,597.39
Rate for Payer: SELF PAY	$48,000.00
Rate for Payer: Tricare West Military	$42,837.65

Wound debridement and skin graft except hand for musculoskeletal and connective tissue disorders with MCC

Facility

$115,200.00

Service Code	MSDRG 463
Min. Negotiated Rate	$55,265.97
Max. Negotiated Rate	$61,406.63
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$61,406.63
Rate for Payer: American Health Plans Medicare Advantage	$61,406.63
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$61,406.63
Rate for Payer: CIGNA Medicare Advantage	$61,406.63
Rate for Payer: HealthChoice Utah Medicare Advantage	$61,406.63
Rate for Payer: Humana Medicare Advantage	$61,406.63
Rate for Payer: Medicare	$61,406.63
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$61,406.63
Rate for Payer: MOLINA MEDICARE	$61,406.63
Rate for Payer: Pacific Source Medicare Advantage	$61,406.63
Rate for Payer: Select Health Medicare Advantage	$61,406.63
Rate for Payer: SELF PAY	$57,600.00
Rate for Payer: Tricare West Military	$55,265.97

Wound debridement and skin graft except hand for musculoskeletal and connective tissue disorders without CC/MCC

Facility

$86,400.00

Service Code	MSDRG 465
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

Know your out-of-pocket cost for care.

All Charges