Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

LACTIC ACID

Facility

$44.49

Service Code	CPT 83605
Hospital Revenue Code	300
Min. Negotiated Rate	$22.25
Max. Negotiated Rate	$22.25
Rate for Payer: SELF PAY	$22.25

LANCET

Facility

$11.84

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

LANCET WP

Facility

$11.84

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

Laparoscopic cholecystectomy without C.D.E. with CC

Facility

$64,000.00

Service Code	MSDRG 418
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

Laparoscopic cholecystectomy without C.D.E. with MCC

Facility

$86,400.00

Service Code	MSDRG 417
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

Laparoscopic cholecystectomy without C.D.E. without CC/MCC

Facility

$64,000.00

Service Code	MSDRG 419
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

LARGE BORE NG TUBE

Facility

$12.22

Hospital Revenue Code	270
Min. Negotiated Rate	$6.11
Max. Negotiated Rate	$6.11
Rate for Payer: SELF PAY	$6.11

LARGE BORE NG TUBE WP

Facility

$12.22

Hospital Revenue Code	270
Min. Negotiated Rate	$6.11
Max. Negotiated Rate	$6.11
Rate for Payer: SELF PAY	$6.11

LARGE SPU WRAP VEST

Facility

$135.20

Hospital Revenue Code	270
Min. Negotiated Rate	$67.60
Max. Negotiated Rate	$67.60
Rate for Payer: SELF PAY	$67.60

LARRY TUBE

Facility

$401.84

Hospital Revenue Code	270
Min. Negotiated Rate	$200.92
Max. Negotiated Rate	$200.92
Rate for Payer: SELF PAY	$200.92

Laryngoscope Blade Mac 0

Facility

$36.72

Hospital Revenue Code	270
Min. Negotiated Rate	$18.36
Max. Negotiated Rate	$18.36
Rate for Payer: SELF PAY	$18.36

Laryngoscope Blade Mac 4

Facility

$36.72

Hospital Revenue Code	270
Min. Negotiated Rate	$18.36
Max. Negotiated Rate	$18.36
Rate for Payer: SELF PAY	$18.36

Laryngoscope Blade Miller 2

Facility

$36.72

Hospital Revenue Code	270
Min. Negotiated Rate	$18.36
Max. Negotiated Rate	$18.36
Rate for Payer: SELF PAY	$18.36

Laryngoscope Blade Miller 3

Facility

$36.72

Hospital Revenue Code	270
Min. Negotiated Rate	$18.36
Max. Negotiated Rate	$18.36
Rate for Payer: SELF PAY	$18.36

Laryngoscope Blade Miller 4

Facility

$36.72

Hospital Revenue Code	270
Min. Negotiated Rate	$18.36
Max. Negotiated Rate	$18.36
Rate for Payer: SELF PAY	$18.36

LDH

Facility

$3.16

Service Code	CPT 83615
Hospital Revenue Code	300
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$1.58
Rate for Payer: SELF PAY	$1.58

LDL CHOLESTROL

Facility

$3.60

Service Code	CPT 83721
Hospital Revenue Code	300
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$1.80
Rate for Payer: SELF PAY	$1.80

LEADS

Facility

$3.90

Hospital Revenue Code	270
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$1.95
Rate for Payer: SELF PAY	$1.95

LEG BAG CONNECTING TUBE 18"

Facility

$1.78

Hospital Revenue Code	270
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$0.89
Rate for Payer: SELF PAY	$0.89

LEMON GLYCERIN SWABS

Facility

$0.22

Hospital Revenue Code	270
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.11
Rate for Payer: SELF PAY	$0.11

LEMON GLYCERIN SWABS WP

Facility

$0.22

Hospital Revenue Code	270
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.11
Rate for Payer: SELF PAY	$0.11

LFT

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

Limb Holders / Restraints

Facility

$23.82

Hospital Revenue Code	270
Min. Negotiated Rate	$11.91
Max. Negotiated Rate	$11.91
Rate for Payer: SELF PAY	$11.91

Limb reattachment, hip and femur procedures for multiple significant trauma

Facility

$86,400.00

Service Code	MSDRG 956
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

LIPASE

Facility

$24.00

Service Code	CPT 83690
Hospital Revenue Code	300
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$12.00
Rate for Payer: SELF PAY	$12.00

Know your out-of-pocket cost for care.

All Charges