Avita Health System is committed to offering fair and competitive prices to our patients. The amount you will owe depends on many factors, including the services rendered and your insurance plan.

Call our Customer Service team today for a personalized estimate.

419-468-0512
Toll Free: 1-833-462-8428
Monday-Friday
8:00am – 5:00pm

What should I expect when I have scheduled or outpatient services at Avita?
To best serve you, Avita representatives will provide you with a personalized estimate based on your insurance plan and will discuss payment arrangements with you.


In compliance with state and federal laws, Avita Health System is providing these price lists containing common hospital charges. Please remember that while hospital charges are the same for all patients, your patient responsibility may vary based on many factors.

The information provided below is a list of common hospital charges as they appear in our chargemaster, in compliance with state and federal laws. Please remember that while hospital charges are the same for all patients, your patient responsibility may vary based on many factors as discussed here. These lists should not be used to compare and shop between hospitals or estimate out-of-pocket costs for health care services.

For more information about the cost of your care, please contact our Customer Service team so they can provide a personalized estimate for services and to discuss Avita’s payment options.
Representatives are available Monday thru Friday 8:00am-5:00pm at 419-468-0512
(toll free 1-833-462-8428).

Please click here for a machine-readable list of Avita’s standard hospital charges.

OUTPATIENT LABS

Lab Test CPT Charge Before Insurance or Discount
Venipuncture
This is charged for labs collected via blood draw
36415 $7.00
APTT 85730 $55.00
Basic Metabolic Panel 80048 $23.00
Calcium 82310 $35.00
CBC & Platelet with Differential 85025 $24.00
Comprehensive Metabolic Panel 80053 $32.00
Creatinine 82565 $16.00
Glucose 82947 $12.00
Hemoglobin 85018 $30.00
Hemoglobin A1C 83036 $29.00
Hepatic Panel 80076 $19.00
Lipid Panel 80061 $37.00
Magnesium 83735 $58.00
Phosphorus 84100 $55.00
Potassium 84132 $26.00
Prothrombin Time 85610 $12.00
Sedimentation Rate 85651 $44.00
Sensitivity Study 87186 $26.00
Sodium 84295 $26.00
Thyroid Stimulating Hormone 84443 $50.00
Thyroxine, Free T4 84439 $109.00
Troponin 84494 $119.00
Urinalysis with Microscope 81001 $10.00
Urine Culture with Colony 87086 $25.00
Urine Culture with Organism ID 87088 $96.00

COMMON OUTPATIENT IMAGING

The following charges reflect the most common outpatient imaging services. Patients may have
different or additional charges, depending on the services performed. Fees for the Radiologist
provider will be billed separately.

CT and MRI Charges

Imaging Test CPT Charge Before Insurance or Discount
CT Abdomen with Contrast 74160 $3,496.00
CT Chest with Contrast (Thorax) 71260 $2,134.00
CT Head with & without Contrast 70470 $1,879.00
CT Head without Contrast 70450 $1,406.00
CT Pelvis with Contrast 72193 $2,683.00
MRI Brain with & without Contrast 70553 $5,703.00
MRI Lumbar Spine without Contrast 72148 $3,349.00

X-Ray (XR) Charges

Imaging Test CPT Charge Before Insurance or Discount
XR Abdomen (KUB) 74000 $336.00
XR Acute Abdominal Series 74022 $462.00
XR Ankle 73610 $320.00
XR Chest – Portable 71010 $230.00
XR Chest 2 views (PA & Lateral) 71020 $241.00
XR Foot 73630 $321.00
XR Hand/Fingers 73140 $244.00
XR Hip and Pelvis 73502 $257.00
XR Lumbar Spine 2 views (PA & Lateral) 72100 $422.00
XR Pelvis 72170 $219.00

Other Imaging Charges

Imaging Test CPT Charge Before Insurance or Discount
Bone Density Scan (Dexa) 78306 $1,725.00
Mammogram, Screening G0202 $214.00
Modified Barium Swallow 74230 $357.00
Thyroid Uptake 78012 $806.00
Ultrasound Abdomen Complete 76700 $907.00
Ultrasound Carotid Duplex Bilateral 93880 $692.00
Ultrasound Gallbladder 76705 $660.00

COMMON OUTPATIENT THERAPY

The following charges reflect the most common outpatient therapy services offered. Patients may have
additional charges, depending on the services performed.

Physical Therapy

Therapy CPT Charge Before Insurance or Discount
Evaluation – Moderate Complexity 97162 $290.00
Electrical Stimulation 97014 $30.00
Gait Training – 15 minutes each 97116 $90.00
Manual Therapy – 15 minutes each 97140 $166.00
Therapeutic Activity – 15 minutes each 97530 $97.00
Therapeutic Exercise – 15 minutes each 97110 $105.00
Ultrasound 97035 $126.00

Occupational Therapy

Therapy CPT Charge Before Insurance or Discount
Evaluation – Moderate Complexity 97166 $290.00
Therapeutic Activity – 15 minutes each 97530 $97.00
Therapeutic Exercise – 15 minutes each 97110 $105.00

OUTPATIENT CARDIOPULMONARY SERVICES

The following charges reflect the most common outpatient cardiopulmonary services. Patients may have
different or additional charges, depending on the services performed. Fees for the provider are
billed separately.

Diagnostic Testing

Cardiopulmonary Service CPT Charge Before Insurance or Discount
EKG 12-Lead 93005 $139.00
Holter Monitor – Recording 93225 $213.00
Hour Holter Monitor – Scanning 93226 $546.00
Pulmonary Function Study Includes 4 tests $800.00

EEGs/EMGs

Cardiopulmonary Service CPT Charge Before Insurance or Discount
EMG One Extremity Includes 2 tests $644.00
EMG Two Extremities Includes 3 tests $1,066.00
EEG – Up to 60 minutes 95816 $798.00

Stress Tests

Cardiopulmonary Service CPT Charge Before Insurance or Discount
Echo Complete with Doppler 93306 $1,369.00
Stress Test – Echo 93350 $2,243.00
Stress Test with EKG Monitoring 93017 $1,007.00
Stress Test – All Cardiolites 78452 $2,822.00

AVITA WALK-IN CLINICS

Avita has two Walk-In Clinics located in Bellville and Ontario to provide convenient, fast treatment
for injuries and conditions that are not critical, but need prompt attention. For more information,
click here.

Walk-In Clinic charges are based on the level of care needed to treat our patients (with Level 1
representing basic urgent care). The following charges do not include fees for drugs, supplies, or
additional services provided during treatment.

Level of Care CPT Charge Before Insurance or Discount
Level 1 99211 $28.00
Level 2 99212 $89.50
Level 3 99213 $149.00
Level 4 99214 $219.00
Level 5 99215 $294.50

EMERGENCY SERVICES

Avita has three Emergency Departments located in Ontario, Galion, and Bucyrus. Click
here
for more information.

Emergency Department charges are based on the level of emergency care needed to treat our patients
(with Level 1 representing basic emergency care). The following charges do not include fees for
drugs, supplies, or additional services provided during treatment. These also only reflect the
Hospital level charges and do not include fees for the Emergency Department physicians, which is
billed separately.

Level of Care CPT Charge Before Insurance or Discount
Level 1 99281 $184.00
Level 2 99282 $320.00
Level 3 99283 $454.00
Level 4 99284 $728.00
Level 5 99285 $1,085.00

ROOM CHARGES

Room and Board charges reflect the type of care needed to provide treatment. Operating Room charges
are based on the level of care needed to treat our patients (with Level 1 representing basic care).
The following charges do not include fees for drugs, supplies, or additional services provided
during treatment. These also only reflect the Hospital level charges and do not include fees for
the physicians, which is billed separately.

Room and Board – per day

Room Charge Charge Before Insurance or Discount
Routine Care $669.00
Intensive Care (ICU) $1,394.00
Labor & Delivery (Obstetrics) $669.00
Nursery $669.00
Inpatient Rehab $849.00
Swingbed $501.00

Operating Room – up to 30 minutes

Room Charge Charge Before Insurance or Discount
Level 1 $2,283.00
Level 2 $2,592.00
Level 3 $2,834.00
Level 4 $3,132.00
Level 5 $3,418.00

DID YOU KNOW?

Avita Can Estimate Your Cost of Services.

We look at the services and your benefits to provide an accurate estimate of your expected patient
responsibility.

Call our Customer Service team at 419-468-0512 (toll free 1-833-462-8428).
Representatives are available Monday thru Friday 8:00a-5:00p.

Avita Offers Many Payment Options

If you have concerns about your ability to pay for healthcare, our Customer Service team can help:

  1. Avita accepts all major payment methods:
    • Cash
    • Check
    • Debit Card
    • Money Order
    • e-Check
    • Visa
    • Mastercard
    • Discover
    • American Express
  2. Avita offers a generous Financial Assistance program.
  • Review our
    income guidelines.
  • Print
    and mail an application.
  • Payment Plans
    • Short-term payment plans (up to 3 months) can be set up through Avita. Payments can
      be automated through your preferred card or bank account.
    • Long-term payment plans (up to 36 months) can be set up through our partner HELP
      Financial.

Avita Can Help Answer Your Questions

Customer Service

If you have questions about your bill and payment options, contact our customer service team at:

419-468-0512

Toll free: 1-833-462-8428

Financial Counselors

If you have questions about Avita’s financial assistance program or need help applying for Medicaid,
contact our Financial Counselors at any of the following locations:

Bucyrus Hospital……….419-468-0512

Galion Hospital………….419-468-0852
………………………………….419-468-0516
………………………………….419-468-0515

Ontario Hospital………..419-462-3386

Patient Billing Advocates

If you need assistance with your medical bills and insurance letters, or help applying for Medicaid,
contact our Patient Billing Advocates at one of the following locations:

Bucyrus Hospital……….419-563-9810

Galion Hospital………….419-468-0513