Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

HEPATITIS PANEL, CHRONIC 86705

Facility

$49.86

Service Code	CPT 86705
Hospital Revenue Code	300
Min. Negotiated Rate	$24.93
Max. Negotiated Rate	$24.93
Rate for Payer: SELF PAY	$24.93

HEPATITIS PANEL, CHRONIC 86706

Facility

$49.86

Service Code	CPT 86706
Hospital Revenue Code	300
Min. Negotiated Rate	$24.93
Max. Negotiated Rate	$24.93
Rate for Payer: SELF PAY	$24.93

HEPATITIS PANEL, CHRONIC 86803

Facility

$49.86

Service Code	CPT 86803
Hospital Revenue Code	300
Min. Negotiated Rate	$24.93
Max. Negotiated Rate	$24.93
Rate for Payer: SELF PAY	$24.93

HEPATITIS PANEL, CHRONIC 87340

Facility

$49.86

Service Code	CPT 87340
Hospital Revenue Code	300
Min. Negotiated Rate	$24.93
Max. Negotiated Rate	$24.93
Rate for Payer: SELF PAY	$24.93

Hepatobiliary diagnostic procedures with CC

Facility

$51,200.00

Service Code	MSDRG 421
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

Hepatobiliary diagnostic procedures with MCC

Facility

$70,400.00

Service Code	MSDRG 420
Min. Negotiated Rate	$30,972.26
Max. Negotiated Rate	$34,413.62
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$34,413.62
Rate for Payer: American Health Plans Medicare Advantage	$34,413.62
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$34,413.62
Rate for Payer: CIGNA Medicare Advantage	$34,413.62
Rate for Payer: HealthChoice Utah Medicare Advantage	$34,413.62
Rate for Payer: Humana Medicare Advantage	$34,413.62
Rate for Payer: Medicare	$34,413.62
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$34,413.62
Rate for Payer: MOLINA MEDICARE	$34,413.62
Rate for Payer: Pacific Source Medicare Advantage	$34,413.62
Rate for Payer: Select Health Medicare Advantage	$34,413.62
Rate for Payer: SELF PAY	$35,200.00
Rate for Payer: Tricare West Military	$30,972.26

Hepatobiliary diagnostic procedures without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 422
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

Hernia procedures except inguinal and femoral with CC

Facility

$64,000.00

Service Code	MSDRG 354
Min. Negotiated Rate	$27,594.78
Max. Negotiated Rate	$30,660.87
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$30,660.87
Rate for Payer: American Health Plans Medicare Advantage	$30,660.87
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$30,660.87
Rate for Payer: CIGNA Medicare Advantage	$30,660.87
Rate for Payer: HealthChoice Utah Medicare Advantage	$30,660.87
Rate for Payer: Humana Medicare Advantage	$30,660.87
Rate for Payer: Medicare	$30,660.87
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$30,660.87
Rate for Payer: MOLINA MEDICARE	$30,660.87
Rate for Payer: Pacific Source Medicare Advantage	$30,660.87
Rate for Payer: Select Health Medicare Advantage	$30,660.87
Rate for Payer: SELF PAY	$32,000.00
Rate for Payer: Tricare West Military	$27,594.78

Hernia procedures except inguinal and femoral with MCC

Facility

$76,800.00

Service Code	MSDRG 353
Min. Negotiated Rate	$38,828.92
Max. Negotiated Rate	$43,143.24
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$43,143.24
Rate for Payer: American Health Plans Medicare Advantage	$43,143.24
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$43,143.24
Rate for Payer: CIGNA Medicare Advantage	$43,143.24
Rate for Payer: HealthChoice Utah Medicare Advantage	$43,143.24
Rate for Payer: Humana Medicare Advantage	$43,143.24
Rate for Payer: Medicare	$43,143.24
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$43,143.24
Rate for Payer: MOLINA MEDICARE	$43,143.24
Rate for Payer: Pacific Source Medicare Advantage	$43,143.24
Rate for Payer: Select Health Medicare Advantage	$43,143.24
Rate for Payer: SELF PAY	$38,400.00
Rate for Payer: Tricare West Military	$38,828.92

Hernia procedures except inguinal and femoral without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 355
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

HGB

Facility

$11.20

Service Code	CPT 85018
Hospital Revenue Code	300
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$5.60
Rate for Payer: SELF PAY	$5.60

HI-FLOW MUFFLER

Facility

$180.00

Hospital Revenue Code	270
Min. Negotiated Rate	$90.00
Max. Negotiated Rate	$90.00
Rate for Payer: SELF PAY	$90.00

High Complexity Evaluation

Facility

$111.00

Hospital Revenue Code	430
Min. Negotiated Rate	$55.50
Max. Negotiated Rate	$55.50
Rate for Payer: SELF PAY	$55.50

High Complexity Evaluation

Facility

$111.00

Service Code	CPT 97163
Hospital Revenue Code	420
Min. Negotiated Rate	$55.50
Max. Negotiated Rate	$55.50
Rate for Payer: SELF PAY	$55.50

Hill Rom SAE

Facility

$69.00

Hospital Revenue Code	290
Min. Negotiated Rate	$34.50
Max. Negotiated Rate	$34.50
Rate for Payer: SELF PAY	$34.50

Hip and femur procedures except major joint with CC

Facility

$112,000.00

Service Code	MSDRG 481
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

Hip and femur procedures except major joint with MCC

Facility

$112,000.00

Service Code	MSDRG 480
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

Hip and femur procedures except major joint without CC/MCC

Facility

$112,000.00

Service Code	MSDRG 482
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

Hip replacement with principal diagnosis of hip fracture with MCC

Facility

$70,400.00

Service Code	MSDRG 521
Min. Negotiated Rate	$31,579.40
Max. Negotiated Rate	$35,088.22
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$35,088.22
Rate for Payer: American Health Plans Medicare Advantage	$35,088.22
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$35,088.22
Rate for Payer: CIGNA Medicare Advantage	$35,088.22
Rate for Payer: HealthChoice Utah Medicare Advantage	$35,088.22
Rate for Payer: Humana Medicare Advantage	$35,088.22
Rate for Payer: Medicare	$35,088.22
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$35,088.22
Rate for Payer: MOLINA MEDICARE	$35,088.22
Rate for Payer: Pacific Source Medicare Advantage	$35,088.22
Rate for Payer: Select Health Medicare Advantage	$35,088.22
Rate for Payer: SELF PAY	$35,200.00
Rate for Payer: Tricare West Military	$31,579.40

Hip replacement with principal diagnosis of hip fracture without MCC

Facility

$64,000.00

Service Code	MSDRG 522
Min. Negotiated Rate	$27,594.78
Max. Negotiated Rate	$30,660.87
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$30,660.87
Rate for Payer: American Health Plans Medicare Advantage	$30,660.87
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$30,660.87
Rate for Payer: CIGNA Medicare Advantage	$30,660.87
Rate for Payer: HealthChoice Utah Medicare Advantage	$30,660.87
Rate for Payer: Humana Medicare Advantage	$30,660.87
Rate for Payer: Medicare	$30,660.87
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$30,660.87
Rate for Payer: MOLINA MEDICARE	$30,660.87
Rate for Payer: Pacific Source Medicare Advantage	$30,660.87
Rate for Payer: Select Health Medicare Advantage	$30,660.87
Rate for Payer: SELF PAY	$32,000.00
Rate for Payer: Tricare West Military	$27,594.78

HIV RAPID

Facility

$84.00

Service Code	CPT 87389
Hospital Revenue Code	300
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$42.00
Rate for Payer: SELF PAY	$42.00

HIV with extensive O.R. procedures with MCC

Facility

$86,400.00

Service Code	MSDRG 969
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

HIV with extensive O.R. procedures without MCC

Facility

$86,400.00

Service Code	MSDRG 970
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

HIV with major related condition with CC

Facility

$70,400.00

Service Code	MSDRG 975
Min. Negotiated Rate	$31,579.40
Max. Negotiated Rate	$35,088.22
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$35,088.22
Rate for Payer: American Health Plans Medicare Advantage	$35,088.22
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$35,088.22
Rate for Payer: CIGNA Medicare Advantage	$35,088.22
Rate for Payer: HealthChoice Utah Medicare Advantage	$35,088.22
Rate for Payer: Humana Medicare Advantage	$35,088.22
Rate for Payer: Medicare	$35,088.22
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$35,088.22
Rate for Payer: MOLINA MEDICARE	$35,088.22
Rate for Payer: Pacific Source Medicare Advantage	$35,088.22
Rate for Payer: Select Health Medicare Advantage	$35,088.22
Rate for Payer: SELF PAY	$35,200.00
Rate for Payer: Tricare West Military	$31,579.40

HIV with major related condition with MCC

Facility

$73,600.00

Service Code	MSDRG 974
Min. Negotiated Rate	$51,188.87
Max. Negotiated Rate	$56,876.52
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$56,876.52
Rate for Payer: American Health Plans Medicare Advantage	$56,876.52
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$56,876.52
Rate for Payer: CIGNA Medicare Advantage	$56,876.52
Rate for Payer: HealthChoice Utah Medicare Advantage	$56,876.52
Rate for Payer: Humana Medicare Advantage	$56,876.52
Rate for Payer: Medicare	$56,876.52
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$56,876.52
Rate for Payer: MOLINA MEDICARE	$56,876.52
Rate for Payer: Pacific Source Medicare Advantage	$56,876.52
Rate for Payer: Select Health Medicare Advantage	$56,876.52
Rate for Payer: SELF PAY	$36,800.00
Rate for Payer: Tricare West Military	$51,188.87

Know your out-of-pocket cost for care.

All Charges