Listed to the left are standard charges for common hospital services. Please remember that while
hospital charges are the same for all patients, your patient responsibility may vary based on many
factors. This list is not a helpful tool for patients to comparison shop between hospitals or to
estimate what health care services are going to cost them out of their own pocket. Download
a machine-readable list of Avita’s standard hospital charges.

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.

When you have scheduled or outpatient services at Avita, a representative will provide you with an
accurate estimate of what you are expected to owe for services based on your plan benefits. We will
discuss payment arrangements with you to inform you of Avita’s generous financial options.

Avita can also estimate your cost prior to services. Contact us today for your free personalized
estimate:

  • Via the MyChart website:Visit MyChart to submit a technical billing
    inquiry or customer service request.
  • Call our Customer Service team: 419-468-0512 (toll free 1-833-462-8428 Monday thru Friday 8:00a-5:00p
  • Visit any Avita Hospital: Financial Counselors are
    available Monday thru Friday 8:00a-4:30p

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.

Contact us today for your free personalized estimate:

  • Via the MyChart website: Visit MyChart to submit a technical billing
    inquiry or customer service request.
  • Call our Customer Service team: 419-468-0512 (toll free 1-833-462-8428 Monday thru Friday 8:00a-5:00p
  • Visit any Avita Hospital: Financial Counselors are
    available Monday thru Friday 8:00a-4:30p
  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.
  3. 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

 

OUTPATIENT LABS

Please remember that while hospital charges are the same for all patients, your patient responsibility may vary based on many factors. Contact our Customer Service team for 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).

Lab Test CPT Charge Before Insurance or Discount
Venipuncture This is charged for labs collected
via blood draw
36415 $7.00
ALT (SGPT) 84460 $16.00
Amylase 82150 $68.00
APTT 85730 $58.00
AST (SGOT) 84450 $16.00
Basic Metabolic Panel 80048 $23.00
Calcium 82310 $37.00
CBC & Platelet with Differential 85025 $24.00
Comprehensive Metabolic Panel 80053 $32.00
Creatinine 82565 $16.00
Glucose 82947 $12.00
Hemoglobin 85018 $32.00
Hemoglobin A1C 83036 $29.00
Hepatic Panel 80076 $19.00
Lipid Panel 80061 $37.00
Magnesium 83735 $61.00
Myoglobin 83874 $139.00
Phosphorus 84100 $58.00
Potassium 84132 $27.00
Prothrombin Time 85610 $12.00
PSA 84153 $30.00
Sedimentation Rate 85651 $46.00
Sensitivity Study 87186 $26.00
Sodium 84295 $25.00
Thyroid Stimulating Hormone 84443 $50.00
Thyroxine, Free T4 84439 $63.00
Troponin 84484 $125.00
Urinalysis with Microscope 81001 $10.00
Urine Culture with Colony 87086 $25.00
Urine Culture with Organism ID 87088 $101.00

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.

Please remember that while hospital charges are the same for all patients, your patient
responsibility may vary based on many factors. Contact our Customer Service team for 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).

CT and MRI Charges

Imaging Test CPT Charge Before Insurance or Discount
CT Abdomen with Contrast 74160 $3,671.00
CT Abdomen with & without Contrast 74170 $3,753.00
CT Chest with Contrast (Thorax) 71260 $2,241.00
CT Head with & without Contrast 70470 $1,973.00
CT Head without Contrast 70450 $1,476.00
CT Pelvis with Contrast 72193 $2,817.00
MRI Brain with & without Contrast 70553 $3,528.00
MRI Lumbar Spine without Contrast 72148 $3,516.00

X-Ray (XR) Charges

Imaging Test CPT Charge Before Insurance or Discount
XR Abdomen (KUB) 74000 $353.00
XR Acute Abdominal Series 74022 $485.00
XR Ankle 73610 $790.00
XR Chest – Portable 71010 $242.00
XR Chest 2 views (PA & Lateral) 71020 $253.00
XR Foot 73630 $337.00
XR Hand/Fingers 73140 $256.00
XR Hip and Pelvis 73502 $270.00
XR Knee 73560 $303.00
XR Lumbar Spine 2 views (PA & Lateral) 72100 $443.00
XR Pelvis 72170 $230.00
XR Shoulder 73020 $336.00
XR Wrist 73100 $575.00

Other Imaging Charges

Imaging Test CPT Charge Before Insurance or Discount
Bone Density Scan (Dexa) 78306 $1,811.00
Mammogram, Diagnostic Unilateral G0206 $448.00
Mammogram, Screening G0202 $214.00
Modified Barium Swallow 74230 $375.00
Thyroid Uptake 78012 $846.00
Ultrasound Abdomen Complete 76700 $952.00
Ultrasound Carotid Duplex Bilateral 93880 $727.00
Ultrasound Extremity Non Vascular 76881 $423.00
Ultrasound Gallbladder 76705 $693.00

COMMON OUTPATIENT THERAPY

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

Please remember that while hospital charges are the same for all patients, your patient
responsibility may vary based on many factors. Contact our Customer Service team for 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).

Physical Therapy

Therapy CPT Charge Before Insurance or Discount
Evaluation – Moderate Complexity 97162 $305.00
Electrical Stimulation 97014 $30.00
Gait Training – 15 minutes each 97116 $95.00
Manual Therapy – 15 minutes each 97140 $174.00
Therapeutic Activity – 15 minutes each 97530 $102.00
Therapeutic Exercise – 15 minutes each 97110 $110.00
Ultrasound 97035 $132.00

Occupational Therapy

Therapy CPT Charge Before Insurance or Discount
Evaluation – Moderate Complexity 97166 $305.00
Therapeutic Activity – 15 minutes each 97530 $102.00
Therapeutic Exercise – 15 minutes each 97110 $110.00

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.

Please remember that while hospital charges are the same for all patients, your patient
responsibility may vary based on many factors. Contact our Customer Service team for 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).

Diagnostic Testing

Cardiopulmonary Service CPT Charge Before Insurance or Discount
EKG 12-Lead 93005 $146.00
Holter Monitor – Recording 93225 $224.00
Holter Monitor – Scanning 93226 $573.00
Pulmonary Function Study Includes 3 tests $986.00

EEGs/EMGs

Cardiopulmonary Service CPT Charge Before Insurance or Discount
EMG One Extremity Includes 2 tests $677.00
EMG Two Extremities Includes 3 tests $1,120.00
EEG – Up to 60 minutes 95816 $838.00

Stress Tests

Cardiopulmonary Service CPT Charge Before Insurance or Discount
Echo Complete with Doppler 93306 $1,437.00
Stress Test – Echo 93350 $2,355.00
Stress Test with EKG Monitoring 93017 $1,057.00
Stress Test – All Cardiolites 78452 $4,334.00

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 $32.00
Level 2 99212 $99.00
Level 3 99213 $165.00
Level 4 99214 $242.00
Level 5 99215 $326.00

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 $193.00
Level 2 99282 $336.00
Level 3 99283 $477.00
Level 4 99284 $764.00
Level 5 99285 $1,139.00

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.

Please remember that while hospital charges are the same for all patients, your patient
responsibility may vary based on many factors. Contact our Customer Service team for 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).

Room and Board – per day

Room Charge Charge Before Insurance or Discount
Routine Care $702.00
Intensive Care (ICU) $1,464.00
Labor & Delivery (Obstetrics) $702.00
Nursery $702.00
Inpatient Rehab $891.00
Swingbed $526.00

Operating Room – up to 30 minutes

Room Charge Charge Before Insurance or Discount
Level 1 $2,397.00
Level 2 $2,722.00
Level 3 $2,976.00
Level 4 $3,289.00
Level 5 $3,589.00

PAYMENT OPTIONS

Simple. Easy. Patient Portal.

Through Instamed Patient Portal, you can pay your bill online with or without an
account.

If your statement has a Patient Number, click here to
pay your bill.

 

If your statement has a Account Number, click here to
pay your bill.

Benefits of creating an account

  • View your current statement online
  • View previous statements
  • Save your payment methods
  • View payment history