Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

GLOVE STERILE SMALL

Facility

$0.84

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

GLOVE VINYL MEDIUM

Facility

$12.72

Hospital Revenue Code	270
Min. Negotiated Rate	$6.36
Max. Negotiated Rate	$6.36
Rate for Payer: SELF PAY	$6.36

GLUCERNA

Facility

$5.84

Hospital Revenue Code	270
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$2.92
Rate for Payer: SELF PAY	$2.92

Glucerna 1.2 1500ml

Facility

$8.78

Hospital Revenue Code	270
Min. Negotiated Rate	$4.39
Max. Negotiated Rate	$4.39
Rate for Payer: SELF PAY	$4.39

Glucerna 1.2 8oz

Facility

$1.30

Hospital Revenue Code	270
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.65
Rate for Payer: SELF PAY	$0.65

GLUCERNA WP

Facility

$5.84

Hospital Revenue Code	270
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$2.92
Rate for Payer: SELF PAY	$2.92

GLUCOSE

Facility

$3.16

Service Code	CPT 82947
Hospital Revenue Code	300
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$1.58
Rate for Payer: SELF PAY	$1.58

GLYCOHEMOGLOBIN A1C

Facility

$11.20

Service Code	CPT 83036
Hospital Revenue Code	300
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$5.60
Rate for Payer: SELF PAY	$5.60

GLYCOHEMOGLOBIN W EST

Facility

$11.20

Service Code	CPT 83036
Hospital Revenue Code	300
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$5.60
Rate for Payer: SELF PAY	$5.60

GRADUATE 1000mL

Facility

$0.56

Hospital Revenue Code	270
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.28
Rate for Payer: SELF PAY	$0.28

GRADUATE 1000mL WP

Facility

$0.56

Hospital Revenue Code	270
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.28
Rate for Payer: SELF PAY	$0.28

GRAM STAIN

Facility

$45.00

Service Code	CPT 87205
Hospital Revenue Code	300
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$22.50
Rate for Payer: SELF PAY	$22.50

Group Therapeutic (15")

Facility

$26.00

Service Code	CPT 97150
Hospital Revenue Code	430
Min. Negotiated Rate	$13.00
Max. Negotiated Rate	$13.00
Rate for Payer: SELF PAY	$13.00

Group Therapeutic 1 unit

Facility

$26.00

Service Code	CPT 97150
Hospital Revenue Code	420
Min. Negotiated Rate	$13.00
Max. Negotiated Rate	$13.00
Rate for Payer: SELF PAY	$13.00

Group Treatment (1unit)

Facility

$38.66

Service Code	CPT 92508
Hospital Revenue Code	440
Min. Negotiated Rate	$19.33
Max. Negotiated Rate	$19.33
Rate for Payer: SELF PAY	$19.33

H2O BAG 2000 mL

Facility

$20.34

Hospital Revenue Code	270
Min. Negotiated Rate	$10.17
Max. Negotiated Rate	$10.17
Rate for Payer: SELF PAY	$10.17

HAIR BRUSH

Facility

$0.54

Hospital Revenue Code	270
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.27
Rate for Payer: SELF PAY	$0.27

HAIR BRUSH WP

Facility

$0.54

Hospital Revenue Code	270
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.27
Rate for Payer: SELF PAY	$0.27

Hair Conditioner

Facility

$0.84

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

HAIR PICK

Facility

$0.16

Hospital Revenue Code	270
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.08
Rate for Payer: SELF PAY	$0.08

HAIR PICK WP

Facility

$0.16

Hospital Revenue Code	270
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.08
Rate for Payer: SELF PAY	$0.08

Hand or wrist procedures, except major thumb or joint procedures with CC/MCC

Facility

$86,400.00

Service Code	MSDRG 513
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

Hand or wrist procedures, except major thumb or joint procedures without CC/MCC

Facility

$86,400.00

Service Code	MSDRG 514
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

Hand procedures for injuries

Facility

$51,200.00

Service Code	MSDRG 906
Min. Negotiated Rate	$18,346.93
Max. Negotiated Rate	$20,385.48
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$20,385.48
Rate for Payer: American Health Plans Medicare Advantage	$20,385.48
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$20,385.48
Rate for Payer: CIGNA Medicare Advantage	$20,385.48
Rate for Payer: HealthChoice Utah Medicare Advantage	$20,385.48
Rate for Payer: Humana Medicare Advantage	$20,385.48
Rate for Payer: Medicare	$20,385.48
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$20,385.48
Rate for Payer: MOLINA MEDICARE	$20,385.48
Rate for Payer: Pacific Source Medicare Advantage	$20,385.48
Rate for Payer: Select Health Medicare Advantage	$20,385.48
Rate for Payer: SELF PAY	$25,600.00
Rate for Payer: Tricare West Military	$18,346.93

HCT

Facility

$16.82

Service Code	CPT 85014
Hospital Revenue Code	300
Min. Negotiated Rate	$8.41
Max. Negotiated Rate	$8.41
Rate for Payer: SELF PAY	$8.41

Know your out-of-pocket cost for care.

All Charges