Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

Wound debridements for injuries with CC*

Facility

$99,200.00

Service Code	MSDRG 902
Min. Negotiated Rate	$51,980.97
Max. Negotiated Rate	$57,756.63
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$57,756.63
Rate for Payer: American Health Plans Medicare Advantage	$57,756.63
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$57,756.63
Rate for Payer: CIGNA Medicare Advantage	$57,756.63
Rate for Payer: HealthChoice Utah Medicare Advantage	$57,756.63
Rate for Payer: Humana Medicare Advantage	$57,756.63
Rate for Payer: Medicare	$57,756.63
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$57,756.63
Rate for Payer: MOLINA MEDICARE	$57,756.63
Rate for Payer: Pacific Source Medicare Advantage	$57,756.63
Rate for Payer: Select Health Medicare Advantage	$57,756.63
Rate for Payer: SELF PAY	$49,600.00
Rate for Payer: Tricare West Military	$51,980.97

Wound debridements for injuries with MCC*

Facility

$99,200.00

Service Code	MSDRG 901
Min. Negotiated Rate	$51,980.97
Max. Negotiated Rate	$57,756.63
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$57,756.63
Rate for Payer: American Health Plans Medicare Advantage	$57,756.63
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$57,756.63
Rate for Payer: CIGNA Medicare Advantage	$57,756.63
Rate for Payer: HealthChoice Utah Medicare Advantage	$57,756.63
Rate for Payer: Humana Medicare Advantage	$57,756.63
Rate for Payer: Medicare	$57,756.63
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$57,756.63
Rate for Payer: MOLINA MEDICARE	$57,756.63
Rate for Payer: Pacific Source Medicare Advantage	$57,756.63
Rate for Payer: Select Health Medicare Advantage	$57,756.63
Rate for Payer: SELF PAY	$49,600.00
Rate for Payer: Tricare West Military	$51,980.97

Wound debridements for injuries without CC/MCC

Facility

$86,400.00

Service Code	MSDRG 903
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

Wound Freedom VAC

Facility

$130.90

Hospital Revenue Code	290
Min. Negotiated Rate	$65.45
Max. Negotiated Rate	$65.45
Rate for Payer: SELF PAY	$65.45

XEROFORM

Facility

$1.84

Hospital Revenue Code	270
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$0.92
Rate for Payer: SELF PAY	$0.92

XMAS ADAPTER

Facility

$0.68

Hospital Revenue Code	270
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.34
Rate for Payer: SELF PAY	$0.34

XMAS ADAPTER WP

Facility

$0.68

Hospital Revenue Code	270
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.34
Rate for Payer: SELF PAY	$0.34

Xray 1 Chest View

Facility

$413.52

Hospital Revenue Code	320
Min. Negotiated Rate	$206.76
Max. Negotiated Rate	$206.76
Rate for Payer: SELF PAY	$206.76

Xray 2 Chest View

Facility

$453.34

Hospital Revenue Code	320
Min. Negotiated Rate	$226.67
Max. Negotiated Rate	$226.67
Rate for Payer: SELF PAY	$226.67

Xray Abdomen

Facility

$419.54

Hospital Revenue Code	320
Min. Negotiated Rate	$209.77
Max. Negotiated Rate	$209.77
Rate for Payer: SELF PAY	$209.77

Xray Femur 1 View

Facility

$428.08

Hospital Revenue Code	320
Min. Negotiated Rate	$214.04
Max. Negotiated Rate	$214.04
Rate for Payer: SELF PAY	$214.04

Xray Femur 2 View

Facility

$482.46

Hospital Revenue Code	320
Min. Negotiated Rate	$241.23
Max. Negotiated Rate	$241.23
Rate for Payer: SELF PAY	$241.23

Xray Foot 2 View

Facility

$396.39

Hospital Revenue Code	320
Min. Negotiated Rate	$198.19
Max. Negotiated Rate	$198.19
Rate for Payer: SELF PAY	$198.19

Xray Forearm 1 Views

Facility

$418.46

Hospital Revenue Code	320
Min. Negotiated Rate	$209.23
Max. Negotiated Rate	$209.23
Rate for Payer: SELF PAY	$209.23

Xray Forearm 2 Views

Facility

$463.22

Hospital Revenue Code	320
Min. Negotiated Rate	$231.61
Max. Negotiated Rate	$231.61
Rate for Payer: SELF PAY	$231.61

Xray Humerus 2 Views

Facility

$423.00

Hospital Revenue Code	320
Min. Negotiated Rate	$211.50
Max. Negotiated Rate	$211.50
Rate for Payer: SELF PAY	$211.50

Xray Knee 2 View

Facility

$426.88

Hospital Revenue Code	320
Min. Negotiated Rate	$213.44
Max. Negotiated Rate	$213.44
Rate for Payer: SELF PAY	$213.44

Xray Pelvis 1 View

Facility

$416.48

Hospital Revenue Code	320
Min. Negotiated Rate	$208.24
Max. Negotiated Rate	$208.24
Rate for Payer: SELF PAY	$208.24

Xray Shoulder 2 Views

Facility

$426.56

Hospital Revenue Code	320
Min. Negotiated Rate	$213.28
Max. Negotiated Rate	$213.28
Rate for Payer: SELF PAY	$213.28

Xray Spine Lumboscaral 2 Views

Facility

$434.78

Hospital Revenue Code	320
Min. Negotiated Rate	$217.39
Max. Negotiated Rate	$217.39
Rate for Payer: SELF PAY	$217.39

Xray Spine Thoracic 2 Views

Facility

$428.33

Hospital Revenue Code	320
Min. Negotiated Rate	$214.16
Max. Negotiated Rate	$214.16
Rate for Payer: SELF PAY	$214.16

Xray Tib Fib 1 View

Facility

$421.98

Hospital Revenue Code	320
Min. Negotiated Rate	$210.99
Max. Negotiated Rate	$210.99
Rate for Payer: SELF PAY	$210.99

Xray Tib Fib 2 View

Facility

$470.26

Hospital Revenue Code	320
Min. Negotiated Rate	$235.13
Max. Negotiated Rate	$235.13
Rate for Payer: SELF PAY	$235.13

XSMALL 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

YANKAUER SUCTION BULB TIP

Facility

$1.26

Hospital Revenue Code	270
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$0.63
Rate for Payer: SELF PAY	$0.63

Know your out-of-pocket cost for care.

All Charges