NOTICE REGARDING HEALTH CARE PLAN COVERAGE

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 $605 to $12,419. 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

Charge DescriptionAverage Charge per Account
Complete blood count lab test $473
Single or first dose of medication delivered via IV $298
1000ml bag of saline IV fluids $181
Complete panel of 14 blood tests $983
Basic panel of 7 or 8 blood tests $777
Blood test for pancreatic enzymes $640
Second or each additional dose of medication delivered via IV $484
External recording of the electrical activity of the heart $758
30mg injection of Ketorolac, a non-steroidal anti-inflammatory medication $205
4mg vial of Ondansetron, used to prevent nausea and vomiting $463
Urine test conducted via machine with microscope $558
Blood test of the heart muscle $902
Blood test for pregnancy $350
Low osmolar contrast material used in diagnostic radiology $219
ED PROC CAT 2 $2,291
Acetaminophen 500 mg tablet $2
Chest x-ray with 2 views $1,255
Chest x-ray with 1 view $793
Urine test conducted via machine without microscope $285
Ibuprofen 600mg tablet $5
Each additional hour of IV fluid hydration $263
An injection of medication or vaccine given intramuscular or subcutaneous $222
Computerized tomography "Cat Scan" of the abdomen and pelvis with contrast $5,644
4mg oral dose of Ondansetron, used to prevent nausea and vomiting $15
2ml dose ampule of Fentanyl $235

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NOTICE REGARDING HEALTH CARE PLAN COVERAGE

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 $533 to $12,370. 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 count lab test $449
Single or first dose of medication delivered via IV $293
Blood test for red blood cells $112
Basic panel of 7 or 8 blood tests, with ionized calcium $854
1000ml bag of saline IV fluids $185
External recording of the electrical activity of the heart $720
Second or each additional dose of medication delivered via IV $440
4mg vial of Ondansetron, used to prevent nausea and vomiting $446
30mg injection of Ketorolac, a non-steroidal anti-inflammatory medication $201
Urine test conducted via machine with microscope $97
Catheter (needle) used to start an IV $7
Blood test of the heart muscle $886
Urine test conducted via machine without microscope $229
Low osmolar contrast used in diagnostic radiology $223
Blood test for kidney function $209
Chest x-ray with 2 views $1,246
ER PROCEDURE 2 $2,327
Blood test for pregnancy $354
Blood test for kidney function $482
Blood test for calcium level $549
Blood test for chloride level $260
Blood test for sodium level $260
Blood test for potassium level $257
Blood test for glucose level $205
Blood test for pancreatic enzymes $610

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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 (excluding Mountain Enhanced) All Networks (Excluding PPO) N/A
BrightHealth All Networks (Emergency Only) Not participating N/A
CIGNA All Networks N/A 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
InnoVage N/A 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