Avita Health System is dedicated to providing an extraordinary patient experience. This includes offering fair and competitive prices to our patients. The information provided in this document is in compliance with state and federal laws to provide standard charges (1) as they appear in our chargemaster and (2) for the diagnosis- related groups (DRGs) performed by Avita Health System. Avita can estimate your cost of services: While hospital charges are the same for all patients, your patient responsibility may vary based on many factors. The lists in this document are not helpful tools for patients to comparison shop between hospitals or to estimate what health care services are going to cost them out of their own pocket. 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. (a) Via the MyChart website: Submit a technical billing inquiry or customer service request (b) Call our Customer Service team: 419-468-0512 (toll free 1-833-462-8428) Monday thru Friday 8:00a-5:00p (c) Visit any Avita hospital: Financial Counselors are available Monday thru Friday 8:00a-4:30p 08-06-2019-A-PAC-057 Page 1 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws. Please contact our Customer Service team for a free personalized estimate. Price as of Code Description 07/01/2019 175968 Pocket, Endo Detachable $ 244.92 175972 Straight Zipwire Hydrophilic Guidewire (150Cm .035In/.89Mm) $ 113.16 176880 Amplatz Super Stiff 0.035/260 Cm $ 610.41 177516 Foam Insert For Prone Positioner $ 79.77 177766 Suture 3-0 Silk Strands Black Braided 18" $ 301.29 178663 Tx2 Procedure Pack $ 2,535.00 178664 Lithovue $ 5,055.00 178665 Apligraft $ 3,885.00 182486 Sagittal Blade Flared 48.1 X 0.97 X 90.7 Mm 2108 Series $ 106.11 182487 Arthrex Fiberwire Scissors $ 525.00 182512 Holium 1000 Fortec Fiber $ 1,360.00 183552 Endopath 10Mm Anvil Grasper $ 276.93 185305 Midas Rex 6Mm Burrs (Green) $ 690.00 185306 Midas Rex Dissecting Tool Carbide 3Mm (Peach) $ 786.00 185307 Midas Rex Legend Diamond Wheel 25.4Mm (Peach) $ 648.00 185308 Midas Rex 5Mm Burr (Orange) $ 738.00 185309 Midas Rex 7.5Mm Burr (Orange) $ 738.00 185310 Midas Rex 4Mm Ball (Grey) $ 594.00 187183 Endopath Echelon Endoscopic Lcr W Gst 60Mm Green $ 547.50 187192 Endopath Echelon Endoscopic Lcr W Gst 60Mm Blue $ 547.50 187194 Circular Stapler Curved Ils Long Length 25Mm $ 1,058.31 187195 Endopath Echelon Endoscopic Lcr W Gst 60Mm Gold $ 547.50 187196 Endopath Echelon Endoscopic Lcr W Gst 60Mm Black $ 547.50 187197 Endopath Echelon Endoscopic Lcr W Gst 60Mm White $ 480.27 187198 Harmonic Ace 7 Shears With Advanced Hemostasis $ 1,933.47 187199 Echelon Flex Powered Plus Stapler Long Length 440Mm $ 1,300.53 188801 Lateral Traction Arm Sleeves $ 144.00 188805 Dualmesh Plush 15.0 Cm X 19.0 Cm $ 2,808.00 190418 Ureteral Stent 6X26 Contour $ 342.00 190423 Navigator Ureteral Access Sheath Set 11Fr/13Fr X 36Cm $ 371.76 191342 Biocomposite Achilles Speedbridge $ 5,220.00 191347 Laser Fiber Tractip $ 1,382.25 191349 Zero Tip Basket 5 X 3.0 Fr $ 537.00 191351 Encore Inflator $ 102.00 191354 Forceps Piranha Biopsy $ 971.70 191849 Interpulse With Suction Tubing Handpiece Set $ 85.74 191860 Ez Ifs - Endo $ 885.00 191897 Disposable Lap Metx Scissors 45 Cm $ 1,398.00 191913 Stapler 25Mm Single Use W/4.8Mm $ 3,179.73 191915 Suture Surgidac Endo Stitch 2-0 $ 180.00 191916 Suture Vloc 90 3/0 Violet 9 V-20 $ 93.81 191919 Seam Guard Bariatric $ 515.49 191920 Misonix Bone Scalpel $ 1,619.40 191922 Trocar Endopath Excel Bladeless 15M $ 367.26 193005 Airtap Patient Repositioning System $ 525. 00 193006 Mats Mobile Air Transfer System $ 270.00 193043 Minerva Surgical Handpiece Disposable $ 3,150.00 193045 Flex Support 2009 Compression Bra Sz 32 $ 79.59 193046 Flex Support 2009 Compression Bra Sz 38 $ 101.19 193047 Bra Compression Size 40 White $ 93.63 193048 Flex Support 2009 Compression Bra Sz 44 $ 79.59 193054 Electrode, Abc Dissecting Blade $ 270.33 193057 Dualmesh Plus 18.0Cm X 24.0Cm $ 4,044.00 193059 Hifi Suture With Double Armed Meniscal Needle $ 247.47 193894 Misonix Irrg Tube Set $ 150.00 193895 Misonix Bone Shaver $ 1,529.40 195479 Amplatz Type Renal Dilator/Sheath Set $ 659.28 195480 Sp Tube Introducer Set $ 269.34 195482 Biocue Platelet Concentration Kit $ 3,003.00 195492 Sponge Lap Wash Band Nonsterile $ 241.74 195493 Dakota Basket $ 630.00 195494 Retrieval Basket, Zero Tip 1.9F X 120Cm $ 615.00 195495 Catheter, Ureteral 8/10 Dialator $ 152.52 195501 Catheter, Uretera Dual Lumen Catheter $ 209.10 195503 Scope, Lithovue $ 4,500.00 195504 Endopath 10Bb Babcock W/Handle $ 408.99 195505 Flex 45Mm Reload-Blue 6 Row, 1.5Mm Closed $ 747.60 195507 Large Mesh, Hernia Repair $ 947.52 195510 Stimublast Dbm Putty $ 1,320.00 195511 Stimublast Dbm 5Cc $ 2,400.00 195512 Stimublast Dbm 10Cc $ 3,885.00 02-19-2019-A-PAC-057 Page 2 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws. Please contact our Customer Service team for a free personalized estimate. Price as of Code Description 07/01/2019 195513 Stent, Ureteral 6 X 20 Contour $ 342.00 195514 Stent, Ureteral 6 X 22 Contour $ 342.00 195515 Stent, Ureteral 6 X 24 Contour $ 342.00 195516 Stent, Ureteral 6 X 28 Contour $ 342.00 195517 Clip Duraclip Repositional Hemost $ 375.00 195857 Mesh, Ventralex Medium Hernia $ 2,115.00 195861 Navigator Hd 13/15 X 46 Cm $ 371.76 195865 Polaris Ultra Stent 5Fr X 28Cm $ 430.50 195867 Polaris Ultra Stent 6Fr X 24Cm $ 430.50 195872 Polaris Ultra Stent 6Fr X 26Cm $ 430.50 195873 Feeding Tube Gastrostomy Mic 18Fr $ 114.36 195878 Tube Gastrostomy Mic 22Fr $ 114.36 196624 Tube, Feeding 24 Fr Mic J $ 389.70 196628 Tube, Feeding 22 Fr Mic J $ 982.80 196630 Rt 380 Nail $ 6,781.50 196631 4.2 X 180 Drill $ 405.60 196635 115Mm Lag $ 1,612.05 197142 Securestrap 5Mm Absorbable Strap Fixation Device $ 1,924.38 197760 Stapler Reload 60Mm Gold Endop $ 573.51 197922 Ventralex St Large $ 2,490.00 199295 Gateway Advantage Adapter $ 489.60 199299 Navigator, Hd, 11/13 Fr X 28 Cm $ 371.76 200769 2.5" Silver Soaker Catheters $ 138.00 200771 Fw Bpb #2 Suture Purcase By Box Of 12 Only $ 105.00 200774 Retractor, Vagina Cervical $ 280.08 200782 Ventrio St Hernia Patch Large Cir $ 2,910.00 200786 Uretheral Sheath Set, Navigator Hd 11/F X 28Cm $ 74.34 200789 Toric Upgraded Lens $ 366.00 200790 Eye Pack $ 1,647.00 200791 Standard Lens $ 150.00 200793 Multifocal Lens $ 766.00 200934 Ventrio St Hernia Patch Small Ova 3.1" X 4.7" $ 2,665.62 201091 Cordis Lt Newton Straight Tip .035 150Cm Wire $ 118. 23 201092 Cordis Standard Straight Tip Wire .035 150Cm $ 487. 05 201096 Saber Balloon 3X40 $ 285.00 201099 Cordis .035 260 Straight Guide Wire $ 78. 00 201103 6X30 Saber Balloon $ 1,201.50 201112 8F Angio-Seal Vip $ 247.53 201113 6F/7F Mynxgrip Closure Device $ 66.00 201397 Atrium Prolite Mesh Sheet 10" X 14" $ 411.00 202787 Bost Amplatz .035 Super Stiff Guidewire $ 78.72 203553 132 Degree Cemented Hip Stem $ 25,500.00 206926 Contour Load Cvr Cutter Thick $ 915.30 206927 Stapler Contour Cvd Cutter Reg $ 1,533.66 214932 Margin Markers Sterile Ink Set $ 381.00 215296 Suture, Vloc 180-09.5 Gs-21 $ 96.00 218053 Dual Cut Sagittal Blade 11X1.19X90Mm $ 363.00 218171 Avi Laparascopic Cholangiography Sets $ 458.58 227924 Silicone Tympanostomy Tubes 12X10X1.14 $ 80.91 227925 Laser-Flex Cuffed Endotracheal Tubes 5.0Mm $ 184.83 227927 Laser-Flex Cuffed Endotracheal Tubes 5.5Mm $ 184.83 227929 Laser-Flex Cuffed Endotracheal Tubes 4.5Mm $ 184.83 227932 Laser-Flex Cuffed Endotracheal Tubes 6.0Mm $ 184.83 227935 Laser-Flexed Uncuffed Endotracheal Tubes 3.0Mm $ 179.73 227936 Laser-Flex Uncuffed Endotracheal Tubes 3.5Mm $ 179.73 227938 Laser-Flex Uncuffed Endotrach Tubes 4.0Mm $ 179.73 227941 Manujet Iii Kit W/Jet Ventilation Catheter $ 153.99 229443 Miloop $ 390.00 229450 Ligasure Retractable L-Hook Sealer/Divider $ 2,013.00 230026 Malygun Ring $ 465.00 231338 Novasure Advanced Device $ 3,228.00 232225 6" Coated Needle W/Extended Insulation $ 1,023.00 232226 Stratafix Symmetric Pds Plus Violet 45Cm Ct-1 $ 69.00 232649 Ventralight 6"X8" $ 3,735.00 232664 Ventralight Mesh 7"X9" $ 4,725.00 232665 Ventralight Mesh 6" $ 2,662.50 232666 Ventralight Mesh 6"X10" $ 4,275.00 232667 Ventralight Mesh 6"X8" $ 5,010.00 232668 Ventralight Mesh 7"X9" W/Positioning System $ 4,725.00 232669 Ventralight Mesh 8" $ 4,650.00 232670 Escape Basket $ 730.47 02-19-2019-A-PAC-057 Page 3 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws. Please contact our Customer Service team for a free personalized estimate.