NOTICE REGARDING HEALTH CARE PLAN COVERAGE
This freestanding emergency department (Stapleton Emergency Department ) accepts patients enrolled in the following programs: Colorado Medicaid (Articles 4, 5 and 6 of Title 25.5); Medicare (Title XVIII of the Federal Social Security Act, as amended); the CHIP program (Article 8 of Title 25.5) and a military health plan (10 U.S.C. Section 1071).
The prices listed on this facility’s chargemaster or fee schedule for any given health care service is the maximum charge that any patient will be billed for the service. The actual price for the health care service may be lower depending on your health insurance benefits and the availability of discounts or financial assistance.
This Facility will charge a facility fee with prices ranging approximately and, on average, from $591 to $11,900. In addition to these fees you will be charged for any testing, supplies, or other services you receive. All physicians providing health care services will bill separately from the Facility for services they provided to you.
The health care provider networks and carriers that this Facility participates with are listed on the attached Exhibit 1.
This Facility and/or a physician providing health care services may not be a participating provider in your health insurance provider network.
If you are covered by health insurance, you are strongly encouraged to consult with your health insurer to determine accurate information about your financial responsibility for a particular health care service provided at this Facility. If you are not covered by health insurance, you are strongly encouraged to contact (866) 475-7872 to discuss payment options and the availability of financial assistance prior to receiving a health care service from this Facility.
The average fee schedule price for the twenty-five most common health care services provided by this Facility are listed on the attached Exhibit 2. The prices listed for each health care service is the average charge that you may be billed for the particular service. The actual price for the health care service may be lower depending on your insurance coverage and the availability of discounts or financial assistance.
Stapleton Emergency Department
|Charge Description||Average Charge per Account|
|Complete blood count lab test||$435|
|1000ml bag of saline IV fluids||$367|
|Single or first dose of medication delivered via IV||$467|
|Catheter (needle) used to start an IV||$12|
|30mg injection of Ketorolac, a non-steroidal anti-inflammatory medication||$193|
|Urine test conducted via machine without microscope||$220|
|Complete panel of 14 blood tests||$1,047|
|External recording of the electrical activity of the heart||$720|
|Second or each additional dose of medication delivered via IV||$687|
|Basic panel of 7 or 8 blood tests, with ionized calcium||$846|
|Basic panel of 7 or 8 blood tests, including total calcium||$763|
|Each additional hour of IV fluid hydration||$562|
|ED PROC CAT 2||$1,652|
|4mg vial of Ondansetron, used to prevent nausea and vomiting||$351|
|Intramuscular or subcutaneous injection||$365|
|Blood test for pancreatic enzymes||$76|
|Ibuprofen 600MG tablet||$1|
|Chest x-ray with 2 views||$480|
|Rapid test for group a strep to diagnose strep throat||$69|
|Blood test for pregnancy||$198|
|Urine pregnancy test||$142|
|Blood test for the heart muscle||$881|
|Culture for group A strep||$117|
|4mg oral dose of Ondansetron, used to prevent nausea and vomiting||$2|
|Plan||Commercial Group and Individual||Managed Medicare||Managed Medicaid|
|AETNA (Inc. Coventry and FirstHealth)||All Networks||All Networks||N/A|
|Anthem BCBS||All Networks (excluding Mountain Enhanced)||All Networks (Excluding PPO)||N/A|
|BrightHealth||All Networks (Emergency Only)||Not participating||N/A|
|Clear Spring||N/A||All Networks||N/A|
|Colorado Access||N/A||N/A||All Networks|
|Humana||Not participating||All Networks||N/A|
|Kaiser||All Networks (Swedish ER and Belmar Locations only)||All Networks and locations||N/A|
|Multiplan/PHCS||All Hospital Networks (excluding physician only networks)||N/A||N/A|
|Rocky Mountain Health Plan||All Networks||N/A||All Networks|
|UnitedHealthcare||All Networks (except Colorado Doctors Plan)||All Networks||N/A|