CPT 97165

Occupational Therapy Evaluation - Low Complexity

Standard Price
$332.00
Minimum Price
$96.68
Maximum Price
$408.76
Cash Price
$99.60

The standard charge for Occupational Therapy Evaluation - Low Complexity is $332.00. However, the price you pay depends on the rate negotiated by your insurance plan and what portion your insurance plan requires you to contribute towards that amount. Enter your info below to start your estimate.

To calculate an estimate of your cost, you will need two things:

  • Your Summary of Benefits and Coverage statement from your health insurance plan. If you don't have a paper copy, this is often also available online through your health insurance company's website.
  • Your remaining deductible amount for this year for your insurance plan. Many insurance plans require you to pay a certain amount out of pocket before the insurance kicks in. This amount is called the deductible and is different for each insurance plan.

More Information

Beloit Memorial Hospital

Beloit Memorial Hospital

Beloit Memorial Hospital is committed to empowering our patients to make informed decisions about their healthcare. This includes helping patients understand the cost of care and the availability of financial assistance.

In compliance with federal law, Beloit Memorial Hospital provides a list of standard charges. These are reviewed on an annual basis. Charges for hospital services are not equivalent to the actual amount paid by insurance companies or patients. The amount paid for services is based on many factors, including health insurance benefit plans, applicable discounts, and services provided based on each patient’s unique needs.

DISCLAIMER:

  • I understand that the list of standard charges includes only hospital services and does not contain professional fees for non-Beloit Memorial Hospital physicians or advanced practice providers. It does not contain professional fees for anesthesia, physicians or advanced practice providers.

  • I understand that a single line item charge may not represent a complete medical service. In general, multiple charge line items are necessary to represent all components of a service (e.g. procedures, supplies, and drugs).

  • I understand that the list of standard charges is not intended for media use.

  • I understand prices are the list price of all hospital charges and not necessarily what my insurance company will pay or what I will owe to the hospital. My actual bill may include one or more of list price charges.

  • The hospital typically accepts a rate that is less than the list charges. Your insurer will determine what you will owe after they have paid their agreed upon amount.

  • We know that the billing and payment processes may seem overwhelming at times. Please contact our team at 608-364-5011.

Cost Estimate

Choose a plan to view the insurance rate estimate.

Cost Estimate

  • Total estimated charges

    $332.00

  • Insurance Discount

    -$21.25

  • Price Negotiated by Insurer

    $310.75

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $195.62

  • Basic Metabolic Panel

    $242.42

  • High - Blood Glucose Hi/Lo

    $72.07

  • IM/Subsq Injection - 96372

    $208.73

  • Legal Blood Draw

    $42.12

  • Magnesium, Urine

    $35.57

  • OT TH Therapeutic Exercise Chg

    $208.73

  • Surgicel 1 x 2" [Med]"

    $371.59

  • Yes - PT TH Evaluation Low Complexity Chg

    $310.75

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.

Cost Estimate

  • Total estimated charges

    $332.00

  • Insurance Discount

    -$35.06

  • Price Negotiated by Insurer

    $296.94

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $186.93

  • Basic Metabolic Panel

    $231.65

  • High - Blood Glucose Hi/Lo

    $68.87

  • IM/Subsq Injection - 96372

    $199.45

  • Legal Blood Draw

    $40.25

  • Magnesium, Urine

    $33.99

  • OT TH Therapeutic Exercise Chg

    $199.45

  • Surgicel 1 x 2" [Med]"

    $355.08

  • Yes - PT TH Evaluation Low Complexity Chg

    $296.94

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.

Cost Estimate

  • Total estimated charges

    $332.00

  • Insurance Discount

    -$235.32

  • Price Negotiated by Insurer

    $96.68

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $8.08

  • Basic Metabolic Panel

    $8.80

  • High - Blood Glucose Hi/Lo

    $5.24

  • IM/Subsq Injection - 96372

    $75.77

  • Legal Blood Draw

    $9.71

  • Magnesium, Urine

    $6.97

  • OT TH Therapeutic Exercise Chg

    $64.94

  • Surgicel 1 x 2" [Med]"

    $115.61

  • Yes - PT TH Evaluation Low Complexity Chg

    $96.68

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.

Cost Estimate

  • Total estimated charges

    $332.00

  • Price Negotiated by Insurer

    $362.96

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $30.30

  • Basic Metabolic Panel

    $32.99

  • High - Blood Glucose Hi/Lo

    $19.66

  • IM/Subsq Injection - 96372

    $150.75

  • Legal Blood Draw

    $30.42

  • Magnesium, Urine

    $26.13

  • OT TH Therapeutic Exercise Chg

    $362.96

  • Surgicel 1 x 2" [Med]"

    $268.37

  • Yes - PT TH Evaluation Low Complexity Chg

    $362.96

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.

Cost Estimate

  • Total estimated charges

    $332.00

  • Insurance Discount

    -$33.52

  • Price Negotiated by Insurer

    $298.48

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $14.14

  • Basic Metabolic Panel

    $15.40

  • High - Blood Glucose Hi/Lo

    $9.17

  • IM/Subsq Injection - 96372

    $115.96

  • Legal Blood Draw

    $23.40

  • Magnesium, Urine

    $12.19

  • OT TH Therapeutic Exercise Chg

    $298.48

  • Surgicel 1 x 2" [Med]"

    $206.44

  • Yes - PT TH Evaluation Low Complexity Chg

    $298.48

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.

Cost Estimate

  • Total estimated charges

    $332.00

  • Insurance Discount

    -$49.12

  • Price Negotiated by Insurer

    $282.88

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $13.41

  • Basic Metabolic Panel

    $14.61

  • High - Blood Glucose Hi/Lo

    $8.70

  • IM/Subsq Injection - 96372

    $111.32

  • Legal Blood Draw

    $22.46

  • Magnesium, Urine

    $11.57

  • OT TH Therapeutic Exercise Chg

    $282.88

  • Surgicel 1 x 2" [Med]"

    $198.18

  • Yes - PT TH Evaluation Low Complexity Chg

    $282.88

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.

Cost Estimate

  • Total estimated charges

    $332.00

  • Insurance Discount

    -$149.00

  • Price Negotiated by Insurer

    $183.00

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $115.20

  • Basic Metabolic Panel

    $142.76

  • High - Blood Glucose Hi/Lo

    $42.44

  • IM/Subsq Injection - 96372

    $122.92

  • Legal Blood Draw

    $24.80

  • Magnesium, Urine

    $20.95

  • OT TH Therapeutic Exercise Chg

    $122.92

  • Surgicel 1 x 2" [Med]"

    $218.83

  • Yes - PT TH Evaluation Low Complexity Chg

    $183.00

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.

Cost Estimate

  • Total estimated charges

    $332.00

  • Insurance Discount

    -$232.40

  • Price Negotiated by Insurer

    $99.60

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $62.70

  • Basic Metabolic Panel

    $77.70

  • High - Blood Glucose Hi/Lo

    $23.10

  • IM/Subsq Injection - 96372

    $66.90

  • Legal Blood Draw

    $13.50

  • Magnesium, Urine

    $11.40

  • OT TH Therapeutic Exercise Chg

    $66.90

  • Surgicel 1 x 2" [Med]"

    $119.10

  • Yes - PT TH Evaluation Low Complexity Chg

    $99.60

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.

Cost Estimate

  • Total estimated charges

    $332.00

  • Insurance Discount

    -$14.34

  • Price Negotiated by Insurer

    $317.66

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $199.97

  • Basic Metabolic Panel

    $247.81

  • High - Blood Glucose Hi/Lo

    $73.67

  • IM/Subsq Injection - 96372

    $213.37

  • Legal Blood Draw

    $43.06

  • Magnesium, Urine

    $36.36

  • OT TH Therapeutic Exercise Chg

    $213.37

  • Surgicel 1 x 2" [Med]"

    $379.85

  • Yes - PT TH Evaluation Low Complexity Chg

    $317.66

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.

Cost Estimate

  • Total estimated charges

    $332.00

  • Insurance Discount

    -$138.78

  • Price Negotiated by Insurer

    $193.22

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $121.64

  • Basic Metabolic Panel

    $150.74

  • High - Blood Glucose Hi/Lo

    $44.81

  • IM/Subsq Injection - 96372

    $129.79

  • Magnesium, Urine

    $22.12

  • OT TH Therapeutic Exercise Chg

    $129.79

  • Surgicel 1 x 2" [Med]"

    $231.05

  • Yes - PT TH Evaluation Low Complexity Chg

    $193.22

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.

Cost Estimate

  • Total estimated charges

    $332.00

  • Insurance Discount

    -$24.70

  • Price Negotiated by Insurer

    $307.30

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $193.45

  • Basic Metabolic Panel

    $239.73

  • High - Blood Glucose Hi/Lo

    $71.27

  • IM/Subsq Injection - 96372

    $206.41

  • Legal Blood Draw

    $41.65

  • Magnesium, Urine

    $35.17

  • OT TH Therapeutic Exercise Chg

    $206.41

  • Surgicel 1 x 2" [Med]"

    $367.46

  • Yes - PT TH Evaluation Low Complexity Chg

    $307.30

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.

Cost Estimate

  • Total estimated charges

    $332.00

  • Insurance Discount

    -$14.34

  • Price Negotiated by Insurer

    $317.66

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $199.97

  • Basic Metabolic Panel

    $247.81

  • High - Blood Glucose Hi/Lo

    $73.67

  • IM/Subsq Injection - 96372

    $213.37

  • Legal Blood Draw

    $43.06

  • Magnesium, Urine

    $36.36

  • OT TH Therapeutic Exercise Chg

    $213.37

  • Surgicel 1 x 2" [Med]"

    $379.85

  • Yes - PT TH Evaluation Low Complexity Chg

    $317.66

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.

Cost Estimate

  • Total estimated charges

    $332.00

  • Insurance Discount

    -$121.92

  • Price Negotiated by Insurer

    $210.08

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $30.06

  • Basic Metabolic Panel

    $32.73

  • High - Blood Glucose Hi/Lo

    $19.50

  • IM/Subsq Injection - 96372

    $281.88

  • Legal Blood Draw

    $36.13

  • Magnesium, Urine

    $25.92

  • OT TH Therapeutic Exercise Chg

    $210.08

  • Surgicel 1 x 2" [Med]"

    $309.66

  • Yes - PT TH Evaluation Low Complexity Chg

    $210.08

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.

Cost Estimate

  • Total estimated charges

    $332.00

  • Insurance Discount

    -$55.78

  • Price Negotiated by Insurer

    $276.22

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $173.89

  • Basic Metabolic Panel

    $215.49

  • High - Blood Glucose Hi/Lo

    $64.06

  • IM/Subsq Injection - 96372

    $185.54

  • Legal Blood Draw

    $37.44

  • Magnesium, Urine

    $31.62

  • OT TH Therapeutic Exercise Chg

    $185.54

  • Surgicel 1 x 2" [Med]"

    $330.30

  • Yes - PT TH Evaluation Low Complexity Chg

    $276.22

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.

Cost Estimate

  • Total estimated charges

    $332.00

  • Insurance Discount

    -$124.83

  • Price Negotiated by Insurer

    $207.17

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $12.12

  • Basic Metabolic Panel

    $13.20

  • High - Blood Glucose Hi/Lo

    $7.86

  • IM/Subsq Injection - 96372

    $113.66

  • Legal Blood Draw

    $14.57

  • Magnesium, Urine

    $10.45

  • OT TH Therapeutic Exercise Chg

    $139.15

  • Surgicel 1 x 2" [Med]"

    $247.73

  • Yes - PT TH Evaluation Low Complexity Chg

    $207.17

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.

Cost Estimate

  • Total estimated charges

    $332.00

  • Insurance Discount

    -$14.34

  • Price Negotiated by Insurer

    $317.66

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $199.97

  • Basic Metabolic Panel

    $247.81

  • High - Blood Glucose Hi/Lo

    $73.67

  • IM/Subsq Injection - 96372

    $213.37

  • Legal Blood Draw

    $43.06

  • Magnesium, Urine

    $36.36

  • OT TH Therapeutic Exercise Chg

    $213.37

  • Surgicel 1 x 2" [Med]"

    $379.85

  • Yes - PT TH Evaluation Low Complexity Chg

    $317.66

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.

Cost Estimate

  • Total estimated charges

    $332.00

  • Insurance Discount

    -$162.81

  • Price Negotiated by Insurer

    $169.19

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $106.51

  • Basic Metabolic Panel

    $131.99

  • High - Blood Glucose Hi/Lo

    $39.24

  • IM/Subsq Injection - 96372

    $113.64

  • Legal Blood Draw

    $22.93

  • Magnesium, Urine

    $19.36

  • OT TH Therapeutic Exercise Chg

    $113.64

  • Surgicel 1 x 2" [Med]"

    $202.31

  • Yes - PT TH Evaluation Low Complexity Chg

    $169.19

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.

Cost Estimate

  • Total estimated charges

    $332.00

  • Insurance Discount

    -$107.57

  • Price Negotiated by Insurer

    $224.43

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $141.28

  • Basic Metabolic Panel

    $175.08

  • High - Blood Glucose Hi/Lo

    $52.05

  • IM/Subsq Injection - 96372

    $150.75

  • Legal Blood Draw

    $30.42

  • Magnesium, Urine

    $25.69

  • OT TH Therapeutic Exercise Chg

    $150.75

  • Surgicel 1 x 2" [Med]"

    $268.37

  • Yes - PT TH Evaluation Low Complexity Chg

    $224.43

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.

Cost Estimate

  • Total estimated charges

    $332.00

  • Insurance Discount

    -$124.83

  • Price Negotiated by Insurer

    $207.17

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $8.08

  • Basic Metabolic Panel

    $8.80

  • High - Blood Glucose Hi/Lo

    $5.24

  • IM/Subsq Injection - 96372

    $75.77

  • Legal Blood Draw

    $9.71

  • Magnesium, Urine

    $6.97

  • OT TH Therapeutic Exercise Chg

    $139.15

  • Surgicel 1 x 2" [Med]"

    $247.73

  • Yes - PT TH Evaluation Low Complexity Chg

    $207.17

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.

Cost Estimate

  • Total estimated charges

    $332.00

  • Price Negotiated by Insurer

    $408.76

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $32.32

  • Basic Metabolic Panel

    $35.19

  • High - Blood Glucose Hi/Lo

    $20.97

  • IM/Subsq Injection - 96372

    $303.10

  • Legal Blood Draw

    $38.85

  • Magnesium, Urine

    $27.87

  • OT TH Therapeutic Exercise Chg

    $115.96

  • Surgicel 1 x 2" [Med]"

    $206.44

  • Yes - PT TH Evaluation Low Complexity Chg

    $172.64

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.

Cost Estimate

  • Total estimated charges

    $332.00

  • Insurance Discount

    -$73.04

  • Price Negotiated by Insurer

    $258.96

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $163.02

  • Basic Metabolic Panel

    $202.02

  • High - Blood Glucose Hi/Lo

    $60.06

  • IM/Subsq Injection - 96372

    $173.94

  • Legal Blood Draw

    $35.10

  • Magnesium, Urine

    $29.64

  • OT TH Therapeutic Exercise Chg

    $173.94

  • Yes - PT TH Evaluation Low Complexity Chg

    $258.96

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.

Cost Estimate

  • Total estimated charges

    $332.00

  • Insurance Discount

    -$142.10

  • Price Negotiated by Insurer

    $189.90

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $119.55

  • Basic Metabolic Panel

    $148.15

  • High - Blood Glucose Hi/Lo

    $44.04

  • IM/Subsq Injection - 96372

    $127.56

  • Legal Blood Draw

    $25.74

  • Magnesium, Urine

    $21.74

  • OT TH Therapeutic Exercise Chg

    $127.56

  • Surgicel 1 x 2" [Med]"

    $227.08

  • Yes - PT TH Evaluation Low Complexity Chg

    $189.90

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.

Cost Estimate

  • Total estimated charges

    $332.00

  • Insurance Discount

    -$76.26

  • Price Negotiated by Insurer

    $255.74

  • Deductible Applied

    -

  • Copay

    -

  • Coinsurance

    -

  • Your insurance company will pay

    -

  • You will owe (Estimate)

    -

Associated Charges

Some services may incur additional charges based on the exact care required. Listed below are commonly associated charges with this service and the rate negotiated by your insurance plan. These charges are listed to give you an idea of what types of other services are often required, but not all patients will require these specific services.

  • .Auto Diff

    $160.99

  • Basic Metabolic Panel

    $199.51

  • High - Blood Glucose Hi/Lo

    $59.31

  • IM/Subsq Injection - 96372

    $171.78

  • Legal Blood Draw

    $34.66

  • Magnesium, Urine

    $29.27

  • OT TH Therapeutic Exercise Chg

    $171.78

  • Surgicel 1 x 2" [Med]"

    $305.81

  • Yes - PT TH Evaluation Low Complexity Chg

    $255.74

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Beloit Memorial Hospital so that your price and insurance eligibility can be confirmed.

To verify this rate and discuss any other associated charges to expect, please contact Beloit Memorial Hospital directly.

Click here for contact details.