NOTICE REGARDING HEALTH CARE PLAN COVERAGE

7/1/2020

This freestanding emergency department (Centennial Medical Plaza 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 $863 to $15,980. 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) 475-8266 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.

Centennial Medical Plaza Emergency Department

CentennialAverage charge per account
Single or first dose of medication IV 346
Complete panel of 14 blood tests 1,096
1000ml bag of Saline IV fluids 204
Second or each additional dose delivered IV 526
External recording of the electrical activity of the heart 836
Basic panel of 7 or 8 blood tests including CA 900
Blood test for pancreatic enzymes 724
Blood test for heart muscle 1,014
4mg vial of Ondansetron, used to prevent nausea and vomiting 510
30mg injection of Ketorolac, a non-steroid anti-inflammatory medication 221
Blood test for pregnancy 394
Urine test conducted via machine with micro 611
Urine test conducted via machine without microscope 320
Acetaminophen 500mg tablet 2
Chest X-Ray with 1 view 926
Chest X-Ray with 2 views 1,416
Low osmolar contrast material used in diagnostic radiology 230
ED PROCCAT 2 2,709
IBUPROFEN 600MG TAB 5
Computerized tomography “Cat Scan” of the abdomen and pelvis with contrast 6,533
Each additional hour of IV flu id hydration 289
ED PROC CAT 1 1,121
700mg 5% lidocaine patch 265
Intramuscular subcutaneous injection 268
IBUPROFEN 400MG TAB 5

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NOTICE REGARDING HEALTH CARE PLAN COVERAGE

6/1/2019

This freestanding emergency department (Saddle Rock 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 $863 to $15,980. 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) 475-8266 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.

Saddle Rock Emergency Department

Charge DescriptionAverage Charge per Account
Complete Blood Test $496
Single or first dose of medication IV $337
1000 ML bag of saline IV fluid $186
Blood test for red blood cells $125
Urine test conducted via machine without microscope $286
Basic panel of 7 or 8 blood test, with ionized calcium $935
30mg injection of ketorolac a non-steroid anti-inflammatory medication $209
Second or each additional does of medication delivered via IV $454
Blood test for sodium level $280
Blood test for chloride level $280
External recording of electrical activity of heart $780
Blood test for glucose level $221
Blood test for calcium level $583
Blood test for potassium level $280
Blood test for kidney function $517
Blood urea nitrogen test $280
Catheter (needle) used to start an IV $7
Blood test for heart muscle $1,013
4 mg oral dose of Ondansetron $451
ER PROCEDURE 1 $1,232
Chest XRAY 2 views $1,391
Antihistamine 50 mg injection used to treat allergic reactions $127
Acetaminophen 500 mg tablet $2
IBUPROFEN 600MG TAB $5
Urine Culture lab test $535
Blood test for pregnancy $387

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Contracted Plans

PlanCommercial Group and IndividualManaged MedicareManaged 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
InnoVage N/A 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
OSCAR All Networks N/A N/A
Rocky Mountain Health Plan All Networks All Networks All Networks
UnitedHealthcare All Networks (except Colorado Doctors Plan) All Networks N/A