Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

Hydraguard Silcone Cream 24% W

Facility

$8.60

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

HYDROCELLULAR DRESSING FOAM 6X

Facility

$8.08

Hospital Revenue Code	270
Min. Negotiated Rate	$4.04
Max. Negotiated Rate	$4.04
Rate for Payer: SELF PAY	$4.04

HYDROCOLLOID DRESSING FOAM-BAC

Facility

$4.34

Hospital Revenue Code	270
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$2.17
Rate for Payer: SELF PAY	$2.17
Rate for Payer: SELF PAY	$2.38

HYDROCOLLOID DRESSING THIN 4"X

Facility

$2.42

Hospital Revenue Code	270
Min. Negotiated Rate	$1.21
Max. Negotiated Rate	$1.21
Rate for Payer: SELF PAY	$1.21

HYDROCOLLOID THIN 4X4 WP

Facility

$2.88

Hospital Revenue Code	270
Min. Negotiated Rate	$1.44
Max. Negotiated Rate	$1.44
Rate for Payer: SELF PAY	$1.44

HYDROGEL AMORPHOUS WOUND DRESS

Facility

$11.84

Hospital Revenue Code	270
Min. Negotiated Rate	$5.92
Max. Negotiated Rate	$5.92
Rate for Payer: SELF PAY	$5.92

HYDROGEN PEROXIDE PINT

Facility

$0.96

Hospital Revenue Code	270
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.48
Rate for Payer: SELF PAY	$0.48

HYDROPHILIC FOAM DRESSING FENE

Facility

$8.36

Hospital Revenue Code	270
Min. Negotiated Rate	$4.18
Max. Negotiated Rate	$4.18
Rate for Payer: SELF PAY	$4.18

Hydrophilic Wound Dressing Pas

Facility

$29.72

Hospital Revenue Code	270
Min. Negotiated Rate	$14.86
Max. Negotiated Rate	$14.86
Rate for Payer: SELF PAY	$14.86

Hypertension with MCC

Facility

$70,400.00

Service Code	MSDRG 304
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

Hypertension without MCC

Facility

$51,200.00

Service Code	MSDRG 305
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

Hypertensive encephalopathy with CC

Facility

$67,200.00

Service Code	MSDRG 78
Min. Negotiated Rate	$28,266.26
Max. Negotiated Rate	$31,406.95
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$31,406.95
Rate for Payer: American Health Plans Medicare Advantage	$31,406.95
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$31,406.95
Rate for Payer: CIGNA Medicare Advantage	$31,406.95
Rate for Payer: HealthChoice Utah Medicare Advantage	$31,406.95
Rate for Payer: Humana Medicare Advantage	$31,406.95
Rate for Payer: Medicare	$31,406.95
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$31,406.95
Rate for Payer: MOLINA MEDICARE	$31,406.95
Rate for Payer: Pacific Source Medicare Advantage	$31,406.95
Rate for Payer: Select Health Medicare Advantage	$31,406.95
Rate for Payer: SELF PAY	$33,600.00
Rate for Payer: Tricare West Military	$28,266.26

Hypertensive encephalopathy with MCC

Facility

$76,800.00

Service Code	MSDRG 77
Min. Negotiated Rate	$35,817.33
Max. Negotiated Rate	$39,797.03
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$39,797.03
Rate for Payer: American Health Plans Medicare Advantage	$39,797.03
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$39,797.03
Rate for Payer: CIGNA Medicare Advantage	$39,797.03
Rate for Payer: HealthChoice Utah Medicare Advantage	$39,797.03
Rate for Payer: Humana Medicare Advantage	$39,797.03
Rate for Payer: Medicare	$39,797.03
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$39,797.03
Rate for Payer: MOLINA MEDICARE	$39,797.03
Rate for Payer: Pacific Source Medicare Advantage	$39,797.03
Rate for Payer: Select Health Medicare Advantage	$39,797.03
Rate for Payer: SELF PAY	$38,400.00
Rate for Payer: Tricare West Military	$35,817.33

Hypertensive encephalopathy without CC/MCC

Facility

$60,800.00

Service Code	MSDRG 79
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

ICE BAG WP

Facility

$2.68

Hospital Revenue Code	270
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$1.34
Rate for Payer: SELF PAY	$1.34

IGF BINDING PROTEIN-3

Facility

$47.00

Service Code	CPT 83520
Hospital Revenue Code	300
Min. Negotiated Rate	$23.50
Max. Negotiated Rate	$23.50
Rate for Payer: SELF PAY	$23.50

IMMATURE PLATELET FRACTION

Facility

$6.55

Service Code	CPT 85055
Hospital Revenue Code	300
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$3.27
Rate for Payer: SELF PAY	$3.27

Inborn and other disorders of metabolism

Facility

$70,400.00

Service Code	MSDRG 642
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

Infant CPAP System

Facility

$40.00

Hospital Revenue Code	270
Min. Negotiated Rate	$20.00
Max. Negotiated Rate	$20.00
Rate for Payer: SELF PAY	$20.00

Infections, female reproductive system with CC

Facility

$60,800.00

Service Code	MSDRG 758
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

Infections, female reproductive system with MCC

Facility

$86,400.00

Service Code	MSDRG 757
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

Infections, female reproductive system without CC/MCC

Facility

$51,200.00

Service Code	MSDRG 759
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

Infectious and parasitic diseases with O.R. procedures with CC

Facility

$112,000.00

Service Code	MSDRG 854
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

Infectious and parasitic diseases with O.R. procedures with MCC

Facility

$108,800.00

Service Code	MSDRG 853
Min. Negotiated Rate	$68,108.42
Max. Negotiated Rate	$75,676.02
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$75,676.02
Rate for Payer: American Health Plans Medicare Advantage	$75,676.02
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$75,676.02
Rate for Payer: CIGNA Medicare Advantage	$75,676.02
Rate for Payer: HealthChoice Utah Medicare Advantage	$75,676.02
Rate for Payer: Humana Medicare Advantage	$75,676.02
Rate for Payer: Medicare	$75,676.02
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$75,676.02
Rate for Payer: MOLINA MEDICARE	$75,676.02
Rate for Payer: Pacific Source Medicare Advantage	$75,676.02
Rate for Payer: Select Health Medicare Advantage	$75,676.02
Rate for Payer: SELF PAY	$54,400.00
Rate for Payer: Tricare West Military	$68,108.42

Infectious and parasitic diseases with O.R. procedures without CC/MCC

Facility

$112,000.00

Service Code	MSDRG 855
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

Know your out-of-pocket cost for care.

All Charges