Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

HIV with major related condition without CC/MCC

Facility

$70,400.00

Service Code	MSDRG 976
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 or without other related condition

Facility

$60,800.00

Service Code	MSDRG 977
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

HOT PACK HEATWAVE

Facility

$80.00

Hospital Revenue Code	270
Min. Negotiated Rate	$40.00
Max. Negotiated Rate	$40.00
Rate for Payer: SELF PAY	$40.00

HUDSON RCI CANNULA LARGE

Facility

$50.00

Hospital Revenue Code	270
Min. Negotiated Rate	$25.00
Max. Negotiated Rate	$25.00
Rate for Payer: SELF PAY	$25.00

HUDSON RCI CANNULA LARGE WP

Facility

$42.38

Hospital Revenue Code	270
Min. Negotiated Rate	$21.19
Max. Negotiated Rate	$21.19
Rate for Payer: SELF PAY	$21.19

HUDSON RCI CANNULA MEDIUM

Facility

$50.00

Hospital Revenue Code	270
Min. Negotiated Rate	$25.00
Max. Negotiated Rate	$25.00
Rate for Payer: SELF PAY	$25.00

HUDSON RCI CANNULA MEDIUM WP

Facility

$42.38

Hospital Revenue Code	270
Min. Negotiated Rate	$21.19
Max. Negotiated Rate	$21.19
Rate for Payer: SELF PAY	$21.19

HUDSON RCI CANNULA SMALL

Facility

$50.00

Hospital Revenue Code	270
Min. Negotiated Rate	$25.00
Max. Negotiated Rate	$25.00
Rate for Payer: SELF PAY	$25.00

HUDSON RCI CANNULA SMALL WP

Facility

$42.38

Hospital Revenue Code	270
Min. Negotiated Rate	$21.19
Max. Negotiated Rate	$21.19
Rate for Payer: SELF PAY	$21.19

HUDSON RCI TRACH ADAPTOR

Facility

$52.00

Hospital Revenue Code	270
Min. Negotiated Rate	$26.00
Max. Negotiated Rate	$26.00
Rate for Payer: SELF PAY	$26.00

HUDSON RCI TRACH ADAPTOR WP

Facility

$47.46

Hospital Revenue Code	270
Min. Negotiated Rate	$23.73
Max. Negotiated Rate	$23.73
Rate for Payer: SELF PAY	$23.73

HUGGIES 1

Facility

$20.32

Hospital Revenue Code	270
Min. Negotiated Rate	$10.16
Max. Negotiated Rate	$10.16
Rate for Payer: SELF PAY	$10.16

HUGGIES 2

Facility

$19.76

Hospital Revenue Code	270
Min. Negotiated Rate	$9.88
Max. Negotiated Rate	$9.88
Rate for Payer: SELF PAY	$9.88

HUGGIES 3

Facility

$19.90

Hospital Revenue Code	270
Min. Negotiated Rate	$9.95
Max. Negotiated Rate	$9.95
Rate for Payer: SELF PAY	$9.95

HUGGIES 4

Facility

$20.12

Hospital Revenue Code	270
Min. Negotiated Rate	$10.06
Max. Negotiated Rate	$10.06
Rate for Payer: SELF PAY	$10.06

HUGGIES 5

Facility

$20.40

Hospital Revenue Code	270
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$10.20
Rate for Payer: SELF PAY	$10.20

HUGGIES 6

Facility

$20.32

Hospital Revenue Code	270
Min. Negotiated Rate	$10.16
Max. Negotiated Rate	$10.16
Rate for Payer: SELF PAY	$10.16

HUGGIES NEWBORN

Facility

$16.46

Hospital Revenue Code	270
Min. Negotiated Rate	$8.23
Max. Negotiated Rate	$8.23
Rate for Payer: SELF PAY	$8.23

HUMIDIFIER BYPASS VOCSN WP

Facility

$20.90

Hospital Revenue Code	270
Min. Negotiated Rate	$10.45
Max. Negotiated Rate	$10.45
Rate for Payer: SELF PAY	$10.45

Humidifier QD

Facility

$3.00

Hospital Revenue Code	290
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$1.50
Rate for Payer: SELF PAY	$1.50

HUMID-VENT 1

Facility

$2.50

Hospital Revenue Code	270
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.25
Rate for Payer: SELF PAY	$1.25

HUMID-VENT FILTER

Facility

$6.60

Hospital Revenue Code	270
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$3.30
Rate for Payer: SELF PAY	$3.30

HUMID-VENT FILTER WP

Facility

$6.60

Hospital Revenue Code	270
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$3.30
Rate for Payer: SELF PAY	$3.30

HYBRID ORAL/NASAL CPAP W/ HEAD

Facility

$178.00

Hospital Revenue Code	270
Min. Negotiated Rate	$89.00
Max. Negotiated Rate	$89.00
Rate for Payer: SELF PAY	$89.00

Hydraguard Silcone Cream 24%

Facility

$8.60

Hospital Revenue Code	270
Min. Negotiated Rate	$4.30
Max. Negotiated Rate	$4.30
Rate for Payer: SELF PAY	$4.30

Know your out-of-pocket cost for care.

All Charges