Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

Headaches with MCC

Facility

$86,400.00

Service Code	MSDRG 102
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

Headaches without MCC

Facility

$60,800.00

Service Code	MSDRG 103
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

Heart failure and shock with CC

Facility

$54,400.00

Service Code	MSDRG 292
Min. Negotiated Rate	$22,102.36
Max. Negotiated Rate	$24,558.18
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$24,558.18
Rate for Payer: American Health Plans Medicare Advantage	$24,558.18
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$24,558.18
Rate for Payer: CIGNA Medicare Advantage	$24,558.18
Rate for Payer: HealthChoice Utah Medicare Advantage	$24,558.18
Rate for Payer: Humana Medicare Advantage	$24,558.18
Rate for Payer: Medicare	$24,558.18
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$24,558.18
Rate for Payer: MOLINA MEDICARE	$24,558.18
Rate for Payer: Pacific Source Medicare Advantage	$24,558.18
Rate for Payer: Select Health Medicare Advantage	$24,558.18
Rate for Payer: SELF PAY	$27,200.00
Rate for Payer: Tricare West Military	$22,102.36

Heart failure and shock with MCC

Facility

$67,200.00

Service Code	MSDRG 291
Min. Negotiated Rate	$31,185.36
Max. Negotiated Rate	$34,650.40
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$34,650.40
Rate for Payer: American Health Plans Medicare Advantage	$34,650.40
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$34,650.40
Rate for Payer: CIGNA Medicare Advantage	$34,650.40
Rate for Payer: HealthChoice Utah Medicare Advantage	$34,650.40
Rate for Payer: Humana Medicare Advantage	$34,650.40
Rate for Payer: Medicare	$34,650.40
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$34,650.40
Rate for Payer: MOLINA MEDICARE	$34,650.40
Rate for Payer: Pacific Source Medicare Advantage	$34,650.40
Rate for Payer: Select Health Medicare Advantage	$34,650.40
Rate for Payer: SELF PAY	$33,600.00
Rate for Payer: Tricare West Military	$31,185.36

Heart failure and shock without CC/MCC

Facility

$54,400.00

Service Code	MSDRG 293
Min. Negotiated Rate	$22,102.36
Max. Negotiated Rate	$24,558.18
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$24,558.18
Rate for Payer: American Health Plans Medicare Advantage	$24,558.18
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$24,558.18
Rate for Payer: CIGNA Medicare Advantage	$24,558.18
Rate for Payer: HealthChoice Utah Medicare Advantage	$24,558.18
Rate for Payer: Humana Medicare Advantage	$24,558.18
Rate for Payer: Medicare	$24,558.18
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$24,558.18
Rate for Payer: MOLINA MEDICARE	$24,558.18
Rate for Payer: Pacific Source Medicare Advantage	$24,558.18
Rate for Payer: Select Health Medicare Advantage	$24,558.18
Rate for Payer: SELF PAY	$27,200.00
Rate for Payer: Tricare West Military	$22,102.36

HEATED F&P 60" SINGLE LIMB

Facility

$38.12

Hospital Revenue Code	270
Min. Negotiated Rate	$19.06
Max. Negotiated Rate	$19.06
Rate for Payer: SELF PAY	$19.06

HEEL LANCET

Facility

$9.16

Hospital Revenue Code	270
Min. Negotiated Rate	$4.58
Max. Negotiated Rate	$4.58
Rate for Payer: SELF PAY	$4.58

HEEL LANCET WP

Facility

$9.16

Hospital Revenue Code	270
Min. Negotiated Rate	$4.58
Max. Negotiated Rate	$4.58
Rate for Payer: SELF PAY	$4.58

HEELMEDIX PROTECTOR PETITE

Facility

$90.48

Hospital Revenue Code	270
Min. Negotiated Rate	$45.24
Max. Negotiated Rate	$45.24
Rate for Payer: SELF PAY	$45.24

HEELMEDIX PROTECTOR STANDARD

Facility

$91.80

Hospital Revenue Code	270
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$45.90
Rate for Payer: SELF PAY	$45.90

HEELMEDIX PROTECTOR XL

Facility

$144.76

Hospital Revenue Code	270
Min. Negotiated Rate	$72.38
Max. Negotiated Rate	$72.38
Rate for Payer: SELF PAY	$72.38

HEMATOCRIT

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

HEMATOCRIT HEMOGLOBIN

Facility

$40.00

Service Code	CPT 85014
Hospital Revenue Code	300
Min. Negotiated Rate	$20.00
Max. Negotiated Rate	$20.00
Rate for Payer: SELF PAY	$20.00

HEMOCULT KIT/SLIDE & DEVELOPER

Facility

$1.38

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

HEMOCULT KIT SLIDES

Facility

$1.30

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

Hemodialysis

Facility

$1,625.78

Hospital Revenue Code	800
Min. Negotiated Rate	$812.89
Max. Negotiated Rate	$812.89
Rate for Payer: SELF PAY	$812.89

HEPATIC FUNCTION PANEL

Facility

$9.40

Service Code	CPT 80076
Hospital Revenue Code	300
Min. Negotiated Rate	$4.70
Max. Negotiated Rate	$4.70
Rate for Payer: SELF PAY	$4.70

HEPATITIS A ANTIBODY IGM

Facility

$23.00

Service Code	CPT 86709
Hospital Revenue Code	300
Min. Negotiated Rate	$11.50
Max. Negotiated Rate	$11.50
Rate for Payer: SELF PAY	$11.50

HEPATITIS A DIAG

Facility

$14.25

Service Code	CPT 86708
Hospital Revenue Code	300
Min. Negotiated Rate	$7.12
Max. Negotiated Rate	$7.12
Rate for Payer: SELF PAY	$7.12

HEPATITIS B ANTIBODY CORE

Facility

$24.00

Service Code	CPT 86705
Hospital Revenue Code	300
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$12.00
Rate for Payer: SELF PAY	$12.00

HEPATITIS B CORE

Facility

$24.00

Service Code	CPT 86705
Hospital Revenue Code	300
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$12.00
Rate for Payer: SELF PAY	$12.00

HEPATITIS B SURFACE AB

Facility

$24.00

Service Code	CPT 86706
Hospital Revenue Code	300
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$12.00
Rate for Payer: SELF PAY	$12.00

HEPATITIS B SURFACE AG

Facility

$169.00

Service Code	CPT 87340
Hospital Revenue Code	300
Min. Negotiated Rate	$84.50
Max. Negotiated Rate	$84.50
Rate for Payer: SELF PAY	$84.50

HEPATITIS C ANTIBODY VIRUS HCV

Facility

$27.10

Service Code	CPT 86803
Hospital Revenue Code	300
Min. Negotiated Rate	$13.55
Max. Negotiated Rate	$13.55
Rate for Payer: SELF PAY	$13.55

HEPATITIS PANEL, ACUTE

Facility

$13.60

Service Code	CPT 80074
Hospital Revenue Code	300
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$6.80
Rate for Payer: SELF PAY	$6.80

Know your out-of-pocket cost for care.

All Charges