Western Peaks Specialty Hospital

All Charges

Charge

Type

Setting

Price

LIPID PANEL

Facility

$15.45

Service Code	CPT 80061
Hospital Revenue Code	300
Min. Negotiated Rate	$7.72
Max. Negotiated Rate	$7.72
Rate for Payer: SELF PAY	$7.72

LITHIUM LEVEL

Facility

$7.65

Service Code	CPT 80178
Hospital Revenue Code	300
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$3.83
Rate for Payer: SELF PAY	$3.83

LNCS ADULT EAR PROBE SENSOR

Facility

$63.34

Hospital Revenue Code	270
Min. Negotiated Rate	$31.67
Max. Negotiated Rate	$31.67
Rate for Payer: SELF PAY	$31.67

LNCS ADULT EAR PROBE SENSOR WP

Facility

$63.34

Hospital Revenue Code	270
Min. Negotiated Rate	$31.67
Max. Negotiated Rate	$31.67
Rate for Payer: SELF PAY	$31.67

Local excision and removal of internal fixation devices except hip and femur with CC

Facility

$112,000.00

Service Code	MSDRG 496
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

Local excision and removal of internal fixation devices except hip and femur with MCC

Facility

$112,000.00

Service Code	MSDRG 495
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

Local excision and removal of internal fixation devices except hip and femur without CC/MCC

Facility

$112,000.00

Service Code	MSDRG 497
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

Local excision and removal of internal fixation devices of hip and femur with CC/MCC

Facility

$86,400.00

Service Code	MSDRG 498
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

Local excision and removal of internal fixation devices of hip and femur without CC/MCC

Facility

$86,400.00

Service Code	MSDRG 499
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

LOTION BABY 4oz

Facility

$0.70

Hospital Revenue Code	270
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.35
Rate for Payer: SELF PAY	$0.35

LOTION BABY 4oz WP

Facility

$0.70

Hospital Revenue Code	270
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.35
Rate for Payer: SELF PAY	$0.35

Low Complexity Eval

Facility

$111.00

Service Code	CPT 97161
Hospital Revenue Code	420
Min. Negotiated Rate	$55.50
Max. Negotiated Rate	$55.50
Rate for Payer: SELF PAY	$55.50

Low 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

Lower extremity and humerus procedures except hip, foot and femur with CC

Facility

$112,000.00

Service Code	MSDRG 493
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

Lower extremity and humerus procedures except hip, foot and femur with MCC

Facility

$112,000.00

Service Code	MSDRG 492
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

Lower extremity and humerus procedures except hip, foot and femur without CC/MCC

Facility

$112,000.00

Service Code	MSDRG 494
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

LUBE JELLY 3G PACKET

Facility

$0.18

Hospital Revenue Code	270
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.09
Rate for Payer: SELF PAY	$0.09

LUBE JELLY 3G PACKET WP

Facility

$0.18

Hospital Revenue Code	270
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.09
Rate for Payer: SELF PAY	$0.09

LUTEINIZING HORMONE

Facility

$51.00

Service Code	CPT 83002
Hospital Revenue Code	300
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$25.50
Rate for Payer: SELF PAY	$25.50

LVN NEBULIZER KIT W/WATER

Facility

$12.00

Hospital Revenue Code	270
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$6.00
Rate for Payer: SELF PAY	$6.00

LVN NEBULIZER KIT W/WATER WP

Facility

$12.00

Hospital Revenue Code	270
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$6.00
Rate for Payer: SELF PAY	$6.00

Lymphoma and leukemia with major O.R. procedures with CC

Facility

$86,400.00

Service Code	MSDRG 821
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

Lymphoma and leukemia with major O.R. procedures with MCC

Facility

$115,200.00

Service Code	MSDRG 820
Min. Negotiated Rate	$54,489.95
Max. Negotiated Rate	$60,544.39
Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS	$60,544.39
Rate for Payer: American Health Plans Medicare Advantage	$60,544.39
Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage	$60,544.39
Rate for Payer: CIGNA Medicare Advantage	$60,544.39
Rate for Payer: HealthChoice Utah Medicare Advantage	$60,544.39
Rate for Payer: Humana Medicare Advantage	$60,544.39
Rate for Payer: Medicare	$60,544.39
Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL	$60,544.39
Rate for Payer: MOLINA MEDICARE	$60,544.39
Rate for Payer: Pacific Source Medicare Advantage	$60,544.39
Rate for Payer: Select Health Medicare Advantage	$60,544.39
Rate for Payer: SELF PAY	$57,600.00
Rate for Payer: Tricare West Military	$54,489.95

Lymphoma and leukemia with major O.R. procedures without CC/MCC

Facility

$86,400.00

Service Code	MSDRG 822
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

Lymphoma and non-acute leukemia with CC

Facility

$60,800.00

Service Code	MSDRG 841
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

Know your out-of-pocket cost for care.

All Charges