NOTICE REGARDING HEALTH CARE PLAN COVERAGE
This freestanding emergency department (Belmar 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 $911.53 to $14,157.24. 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) 475-1385 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.
Belmar Emergency Department
Updated January 10, 2022
| Charge Description | Average Charge per Account |
|---|---|
| Complete panel of 14 blood tests | $764 |
| Single or first dose of medication IV | $601 |
| Catheter needle used to start IV | $15 |
| 1000 ML bag of saline IV fluid | $790 |
| Chest XRAY 1 view | $1,266 |
| External recording of electrical activity of heart | $942 |
| Urine test conducted via machine with micro | $347 |
| Blood test for pancreatic enzymes | $495 |
| Basic panel of 7 or 8 blood tests including CA | $585 |
| Blood test for heart muscle | $798 |
| 4mg vial of Ondansetron, used to prevent nausea and vomiting | $254 |
| 15mg injection of Ketorolac, a non-steroid anti-inflammatory medication | $27 |
| Second or each additional dose delivered IV | $823 |
| Blood test for pregnancy | $333 |
| Urine test without microscope | $221 |
| Low osmolar contrast material used in diagnostic radiology | $66 |
| Normal saline 50ml | $684 |
| Each additional hour of IV fluid hydration | $719 |
| Intramuscular or subcutaneous injection | $392 |
| ED PROC CAT 2 | $2,609 |
| Throat swab to check for Group A strep, the cause of strep throat | $130 |
| A sample of blood or other body fluid is taken to test for strep, staph, etc. | $367 |
| Acetamin 500mg | $11 |
| Urine pregnancy test | $193 |
| Computerized tomography "Cat Scan" of the abdomen and pelvis with contrast | $10,838 |
NOTICE REGARDING HEALTH CARE PLAN COVERAGE
This freestanding emergency department (Southwest 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 $911.53 to $14,157.24. 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) 475-1385 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.
Southwest Emergency Department
Updated January 10, 2022
| Charge Description | Average Charge per Account |
|---|---|
| Complete panel of 14 blood tests | $824 |
| Single or first dose of medication IV | $601 |
| 1000 ML bag of saline IV fluid | $780 |
| Catheter needle used to start IV | $14 |
| External recording of electrical activity of heart | $927 |
| Blood test for heart muscle | $897 |
| Chest XRAY 1 view | $1,262 |
| Basic panel of 7 or 8 blood tests including CA | $644 |
| Blood test for pancreatic enzymes | $540 |
| Second or each additional dose delivered IV | $803 |
| 4mg vial of Ondansetron, used to prevent nausea and vomiting | $256 |
| Low osmolar contrast material used in diagnostic radiology | $63 |
| Normal saline 50ml | $673 |
| 15mg injection of Ketorolac, a non-steroid anti-inflammatory medication | $27 |
| Urine test without microscope | $240 |
| Blood test for pregnancy | $362 |
| Urine test conducted via machine with microscope | $377 |
| Computerized tomography "Cat Scan" of the abdomen and pelvis with contrast | $11,715 |
| ED PROC CAT 2 | $2,880 |
| Each additional hour of IV fluid hydration | $807 |
| Computerized tomography "Cat Scan" of the head without contrast | $5,696 |
| Test to rule out blood clot | $969 |
| Drug test for controlled substances | $1,971 |
| Acetamin 500 mg tablet | $12 |
| Intramuscular or subcutaneous injection | $388 |