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||$451|
|Basic panel of 7 or 8 blood tests, with ionized calcium||$936|
|Single or first dose of medication IV||$497|
|Normal saline 1000ml||$401|
|Tubing used for IV||$27|
|Each additional hour of IV fluid hydration||$638|
|30mg injection of Ketorolac, a non-steroid anti-inflammatory medication||$200|
|External recording of electrical activity of heart||$740|
|20 gauge IV||$12|
|Urine test conducted via machine with micro||$272|
|Urine pregnancy test||$167|
|Injection of medication or vaccine given intramuscular or subcutaneous||$381|
|4mg vial of Ondansetron, used to prevent nausea and vomiting||$364|
|ED PROC CAT 1||$1,082|
|Ibuprofen 600 mg tablet||$1|
|ED PROC CAT 2||$1,721|
|Blood test for heart muscle||$1,006|
|Each additional hour of IV fluid hydration||$570|
|Chest x-ray with two views||$536|
|Low osmolar contrast material used in diagnostic radiology||$259|
|Liquid ibuprofen 20mg/ml taken orally||$2|
|20mg tablet corticosteroid used to treat inflammation of skin, joint, lungs and other organs taken orally||$20|
|Inhalation treatment of airway obstruction||$733|
|Administration of a nebulizer||$3|
|Complete panel of 14 blood tests||$1,125|
|Plan||Commercial Group and Individual||Managed Medicare||Managed Medicaid|
|AETNA (Inc. Coventry and FirstHealth)||All Networks||All Networks||N/A|
|Anthem BCBS||All Networks||All Networks||N/A|
|BrightHealth||All Networks (Emergency Only)||Not participating||N/A|
|CIGNA||All Networks||All Networks||N/A|
|Clear Spring||N/A||All Networks||N/A|
|Colorado Access||N/A||N/A||All Networks|
|Friday Health Plan||Not Participating||N/A||N/A|
|Humana||Not participating||All Networks||N/A|
|Kaiser||All Networks (All FSED Locations only)||All Networks and locations||N/A|
|Multiplan/PHCS||All Hospital Networks (excluding physician only networks)||N/A||N/A|
|Mutual of Omaha||N/A||All Networks||N/A|
|Rocky Mountain Health Plan||All Networks||All Networks||All Networks|
|UnitedHealthcare||All Networks (except Colorado Doctors Plan)||All Networks||N/A|