CPT 97162

PT Evaluation - Moderate Complexity

The standard charge for PT Evaluation - Moderate Complexity is $583.00. 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

Samuel Mahelona Memorial Hospital

Samuel Mahelona Memorial Hospital

In compliance with the Centers for Medicare and Medicaid Services (CMS) Final 2020 Price Transparency Rules, effective January 1, 2021, all hospitals in the United States annually must provide a machine-readable file containing negotiated charges (rates) for ALL items and services. Additionally, the rule requires that for 300 shoppable items and services only, hospitals must provide a consumer-friendly display of gross charge and negotiated charges (rates) or estimation tool.

The fees and/or costs provided via this tool are only estimates, and your final bill may be higher or lower than the estimate for various reasons including but not limited to differences in the number of conditions among patients having the same or similar primary procedures, differences in physician ordering practices, unforeseen complications, etc. Moreover, this is not a guarantee of your benefit plan coverage or payment, and the actual payer and patient portion reflected in your final bill may also be higher or lower.

In some instances, where no recent historical claims and/or payment information is available for the payer plan and the item or service you have selected, the estimate may be for the base rate only or not available. Consequently, the estimate may exclude estimates for additional charges and payer payments for services billed in conjunction with the item or service you selected.

Also, this estimate DOES NOT include other services billed for separately by other providers including but not limited to physician or practitioner fees such as pathologist, radiologist, anesthesiologist, physician surgeon or assistant surgeon, etc. If you have questions about your individual situation or were unable to find an estimate for your upcoming service, please contact us at 808-338-9226.

Cost Estimate

Choose a plan to view the insurance rate estimate.

Cost Estimate

  • Total estimated charges

    $583.00

  • Insurance Discount

    -$291.50

  • Price Negotiated by Insurer

    $291.50

  • 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.

  • 97110 - Theurapeutic Proc Ea 15 min

    $99.50

  • 97530 PT Therapeutic Activity Assistant Units

    $123.00

  • azithromycin 200 mg/5 ml 30ml [HHSC]

    $81.97

  • Basic Metabolic Panel (BMP) FSI

    $58.50

  • Blood Glucose Monitoring POC

    $18.00

  • CBC Complete Blood Count w/ Diff FSI

    $57.00

  • Comprehensive Metabolic Panel (CMP) FSI

    $70.50

  • Magnesium Urine Timed FSI

    $47.00

  • Phosphorus FSI

    $33.50

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Samuel Mahelona 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 Samuel Mahelona Memorial Hospital directly at 808-338-9226.

Cost Estimate

  • Total estimated charges

    $583.00

  • Insurance Discount

    -$291.50

  • Price Negotiated by Insurer

    $291.50

  • 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.

  • 97110 - Theurapeutic Proc Ea 15 min

    $99.50

  • 97530 PT Therapeutic Activity Assistant Units

    $123.00

  • azithromycin 200 mg/5 ml 30ml [HHSC]

    $81.97

  • Basic Metabolic Panel (BMP) FSI

    $58.50

  • Blood Glucose Monitoring POC

    $18.00

  • CBC Complete Blood Count w/ Diff FSI

    $57.00

  • Comprehensive Metabolic Panel (CMP) FSI

    $70.50

  • Magnesium Urine Timed FSI

    $47.00

  • Phosphorus FSI

    $33.50

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Samuel Mahelona 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 Samuel Mahelona Memorial Hospital directly at 808-338-9226.

Cost Estimate

  • Total estimated charges

    $583.00

  • Insurance Discount

    -$204.05

  • Price Negotiated by Insurer

    $378.95

  • 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.

  • 97110 - Theurapeutic Proc Ea 15 min

    $129.35

  • 97530 PT Therapeutic Activity Assistant Units

    $159.90

  • azithromycin 200 mg/5 ml 30ml [HHSC]

    $106.57

  • Basic Metabolic Panel (BMP) FSI

    $76.05

  • Blood Glucose Monitoring POC

    $23.40

  • CBC Complete Blood Count w/ Diff FSI

    $74.10

  • Comprehensive Metabolic Panel (CMP) FSI

    $91.65

  • Magnesium Urine Timed FSI

    $61.10

  • Phosphorus FSI

    $43.55

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Samuel Mahelona 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 Samuel Mahelona Memorial Hospital directly at 808-338-9226.

Cost Estimate

  • Total estimated charges

    $583.00

  • Insurance Discount

    -$262.35

  • Price Negotiated by Insurer

    $320.65

  • 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.

  • 97110 - Theurapeutic Proc Ea 15 min

    $109.45

  • 97530 PT Therapeutic Activity Assistant Units

    $135.30

  • azithromycin 200 mg/5 ml 30ml [HHSC]

    $90.17

  • Basic Metabolic Panel (BMP) FSI

    $64.35

  • Blood Glucose Monitoring POC

    $19.80

  • CBC Complete Blood Count w/ Diff FSI

    $62.70

  • Comprehensive Metabolic Panel (CMP) FSI

    $77.55

  • Magnesium Urine Timed FSI

    $51.70

  • Phosphorus FSI

    $36.85

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Samuel Mahelona 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 Samuel Mahelona Memorial Hospital directly at 808-338-9226.

Cost Estimate

  • Total estimated charges

    $583.00

  • Insurance Discount

    -$291.50

  • Price Negotiated by Insurer

    $291.50

  • 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.

  • 97110 - Theurapeutic Proc Ea 15 min

    $99.50

  • 97530 PT Therapeutic Activity Assistant Units

    $123.00

  • azithromycin 200 mg/5 ml 30ml [HHSC]

    $81.97

  • Basic Metabolic Panel (BMP) FSI

    $58.50

  • Blood Glucose Monitoring POC

    $18.00

  • CBC Complete Blood Count w/ Diff FSI

    $57.00

  • Comprehensive Metabolic Panel (CMP) FSI

    $70.50

  • Magnesium Urine Timed FSI

    $47.00

  • Phosphorus FSI

    $33.50

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Samuel Mahelona 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 Samuel Mahelona Memorial Hospital directly at 808-338-9226.

Cost Estimate

  • Total estimated charges

    $583.00

  • Insurance Discount

    -$29.15

  • Price Negotiated by Insurer

    $553.85

  • 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.

  • 97110 - Theurapeutic Proc Ea 15 min

    $189.05

  • 97530 PT Therapeutic Activity Assistant Units

    $233.70

  • azithromycin 200 mg/5 ml 30ml [HHSC]

    $155.75

  • Basic Metabolic Panel (BMP) FSI

    $8.46

  • Blood Glucose Monitoring POC

    $3.28

  • CBC Complete Blood Count w/ Diff FSI

    $7.77

  • Comprehensive Metabolic Panel (CMP) FSI

    $10.56

  • Magnesium Urine Timed FSI

    $6.70

  • Phosphorus FSI

    $4.74

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Samuel Mahelona 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 Samuel Mahelona Memorial Hospital directly at 808-338-9226.

Cost Estimate

  • Total estimated charges

    $583.00

  • Insurance Discount

    -$87.45

  • Price Negotiated by Insurer

    $495.55

  • 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.

  • 97110 - Theurapeutic Proc Ea 15 min

    $169.15

  • 97530 PT Therapeutic Activity Assistant Units

    $209.10

  • azithromycin 200 mg/5 ml 30ml [HHSC]

    $139.36

  • Basic Metabolic Panel (BMP) FSI

    $99.45

  • Blood Glucose Monitoring POC

    $30.60

  • CBC Complete Blood Count w/ Diff FSI

    $96.90

  • Comprehensive Metabolic Panel (CMP) FSI

    $119.85

  • Magnesium Urine Timed FSI

    $79.90

  • Phosphorus FSI

    $56.95

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Samuel Mahelona 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 Samuel Mahelona Memorial Hospital directly at 808-338-9226.

Cost Estimate

  • Total estimated charges

    $583.00

  • Insurance Discount

    -$291.50

  • Price Negotiated by Insurer

    $291.50

  • 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.

  • 97110 - Theurapeutic Proc Ea 15 min

    $99.50

  • 97530 PT Therapeutic Activity Assistant Units

    $123.00

  • azithromycin 200 mg/5 ml 30ml [HHSC]

    $81.97

  • Basic Metabolic Panel (BMP) FSI

    $58.50

  • Blood Glucose Monitoring POC

    $18.00

  • CBC Complete Blood Count w/ Diff FSI

    $57.00

  • Comprehensive Metabolic Panel (CMP) FSI

    $70.50

  • Magnesium Urine Timed FSI

    $47.00

  • Phosphorus FSI

    $33.50

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Samuel Mahelona 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 Samuel Mahelona Memorial Hospital directly at 808-338-9226.

Cost Estimate

  • Total estimated charges

    $583.00

  • Insurance Discount

    -$58.30

  • Price Negotiated by Insurer

    $524.70

  • 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.

  • 97110 - Theurapeutic Proc Ea 15 min

    $179.10

  • 97530 PT Therapeutic Activity Assistant Units

    $221.40

  • azithromycin 200 mg/5 ml 30ml [HHSC]

    $147.56

  • Basic Metabolic Panel (BMP) FSI

    $105.30

  • Blood Glucose Monitoring POC

    $32.40

  • CBC Complete Blood Count w/ Diff FSI

    $102.60

  • Comprehensive Metabolic Panel (CMP) FSI

    $126.90

  • Magnesium Urine Timed FSI

    $84.60

  • Phosphorus FSI

    $60.30

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Samuel Mahelona 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 Samuel Mahelona Memorial Hospital directly at 808-338-9226.

Cost Estimate

  • Total estimated charges

    $583.00

  • Insurance Discount

    -$285.67

  • Price Negotiated by Insurer

    $297.33

  • 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.

  • 97110 - Theurapeutic Proc Ea 15 min

    $101.49

  • 97530 PT Therapeutic Activity Assistant Units

    $125.46

  • azithromycin 200 mg/5 ml 30ml [HHSC]

    $83.61

  • Basic Metabolic Panel (BMP) FSI

    $59.67

  • Blood Glucose Monitoring POC

    $18.36

  • CBC Complete Blood Count w/ Diff FSI

    $58.14

  • Comprehensive Metabolic Panel (CMP) FSI

    $71.91

  • Magnesium Urine Timed FSI

    $47.94

  • Phosphorus FSI

    $34.17

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Samuel Mahelona 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 Samuel Mahelona Memorial Hospital directly at 808-338-9226.

Cost Estimate

  • Total estimated charges

    $583.00

  • Insurance Discount

    -$291.50

  • Price Negotiated by Insurer

    $291.50

  • 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.

  • 97110 - Theurapeutic Proc Ea 15 min

    $99.50

  • 97530 PT Therapeutic Activity Assistant Units

    $123.00

  • azithromycin 200 mg/5 ml 30ml [HHSC]

    $81.97

  • Basic Metabolic Panel (BMP) FSI

    $58.50

  • Blood Glucose Monitoring POC

    $18.00

  • CBC Complete Blood Count w/ Diff FSI

    $57.00

  • Comprehensive Metabolic Panel (CMP) FSI

    $70.50

  • Magnesium Urine Timed FSI

    $47.00

  • Phosphorus FSI

    $33.50

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Samuel Mahelona 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 Samuel Mahelona Memorial Hospital directly at 808-338-9226.

Cost Estimate

  • Total estimated charges

    $583.00

  • Insurance Discount

    -$17.49

  • Price Negotiated by Insurer

    $565.51

  • 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.

  • 97110 - Theurapeutic Proc Ea 15 min

    $193.03

  • 97530 PT Therapeutic Activity Assistant Units

    $238.62

  • azithromycin 200 mg/5 ml 30ml [HHSC]

    $159.03

  • Basic Metabolic Panel (BMP) FSI

    $113.49

  • Blood Glucose Monitoring POC

    $34.92

  • CBC Complete Blood Count w/ Diff FSI

    $110.58

  • Comprehensive Metabolic Panel (CMP) FSI

    $136.77

  • Magnesium Urine Timed FSI

    $91.18

  • Phosphorus FSI

    $64.99

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Samuel Mahelona 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 Samuel Mahelona Memorial Hospital directly at 808-338-9226.

Cost Estimate

  • Total estimated charges

    $583.00

  • Insurance Discount

    -$291.50

  • Price Negotiated by Insurer

    $291.50

  • 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.

  • 97110 - Theurapeutic Proc Ea 15 min

    $99.50

  • 97530 PT Therapeutic Activity Assistant Units

    $123.00

  • azithromycin 200 mg/5 ml 30ml [HHSC]

    $81.97

  • Basic Metabolic Panel (BMP) FSI

    $58.50

  • Blood Glucose Monitoring POC

    $18.00

  • CBC Complete Blood Count w/ Diff FSI

    $57.00

  • Comprehensive Metabolic Panel (CMP) FSI

    $70.50

  • Magnesium Urine Timed FSI

    $47.00

  • Phosphorus FSI

    $33.50

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Samuel Mahelona 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 Samuel Mahelona Memorial Hospital directly at 808-338-9226.

Cost Estimate

  • Total estimated charges

    $583.00

  • Insurance Discount

    -$291.50

  • Price Negotiated by Insurer

    $291.50

  • 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.

  • 97110 - Theurapeutic Proc Ea 15 min

    $99.50

  • 97530 PT Therapeutic Activity Assistant Units

    $123.00

  • azithromycin 200 mg/5 ml 30ml [HHSC]

    $81.97

  • Basic Metabolic Panel (BMP) FSI

    $58.50

  • Blood Glucose Monitoring POC

    $18.00

  • CBC Complete Blood Count w/ Diff FSI

    $57.00

  • Comprehensive Metabolic Panel (CMP) FSI

    $70.50

  • Magnesium Urine Timed FSI

    $47.00

  • Phosphorus FSI

    $33.50

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Samuel Mahelona 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 Samuel Mahelona Memorial Hospital directly at 808-338-9226.

Cost Estimate

  • Total estimated charges

    $583.00

  • Insurance Discount

    -$476.30

  • Price Negotiated by Insurer

    $106.70

  • 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.

  • 97110 - Theurapeutic Proc Ea 15 min

    $17.65

  • 97530 PT Therapeutic Activity Assistant Units

    $18.32

  • azithromycin 200 mg/5 ml 30ml [HHSC]

    $98.37

  • Basic Metabolic Panel (BMP) FSI

    $11.70

  • Blood Glucose Monitoring POC

    $2.50

  • CBC Complete Blood Count w/ Diff FSI

    $10.74

  • Comprehensive Metabolic Panel (CMP) FSI

    $14.61

  • Magnesium Urine Timed FSI

    $9.26

  • Phosphorus FSI

    $6.56

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Samuel Mahelona 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 Samuel Mahelona Memorial Hospital directly at 808-338-9226.

Cost Estimate

  • Total estimated charges

    $583.00

  • Insurance Discount

    -$291.50

  • Price Negotiated by Insurer

    $291.50

  • 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.

  • 97110 - Theurapeutic Proc Ea 15 min

    $99.50

  • 97530 PT Therapeutic Activity Assistant Units

    $123.00

  • azithromycin 200 mg/5 ml 30ml [HHSC]

    $81.97

  • Basic Metabolic Panel (BMP) FSI

    $58.50

  • Blood Glucose Monitoring POC

    $18.00

  • CBC Complete Blood Count w/ Diff FSI

    $57.00

  • Comprehensive Metabolic Panel (CMP) FSI

    $70.50

  • Magnesium Urine Timed FSI

    $47.00

  • Phosphorus FSI

    $33.50

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Samuel Mahelona 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 Samuel Mahelona Memorial Hospital directly at 808-338-9226.

Cost Estimate

  • Total estimated charges

    $583.00

  • Insurance Discount

    -$256.52

  • Price Negotiated by Insurer

    $326.48

  • 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.

  • 97110 - Theurapeutic Proc Ea 15 min

    $111.44

  • 97530 PT Therapeutic Activity Assistant Units

    $137.76

  • azithromycin 200 mg/5 ml 30ml [HHSC]

    $91.81

  • Basic Metabolic Panel (BMP) FSI

    $21.89

  • Blood Glucose Monitoring POC

    $4.68

  • CBC Complete Blood Count w/ Diff FSI

    $20.09

  • Comprehensive Metabolic Panel (CMP) FSI

    $27.32

  • Magnesium Urine Timed FSI

    $17.32

  • Phosphorus FSI

    $12.27

This calculation is an estimate based on the data that you have entered. For verification of pricing, you need to submit this estimate to Samuel Mahelona 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 Samuel Mahelona Memorial Hospital directly at 808-338-9226.