Axillary Sentinel Node Dissection
| DETAIL FOR SERVICES: | Surgery Procedure | Anesthesia | Physician Services |
| 2020 CPT/HCPCS Primary Code | 38525 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| Negotiated Private Fee | $4,170.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| Prossam | $1,300.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| Champva | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| First Medical | $728.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| First Medical Vital | $710.85 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| Plan de Salud Menonita | $1,100.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| Menonita Vital | $739.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| Humana Gold Plus / Gold Choice | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| Humana | $725.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| Mapfre | $781.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| Mcsclassicare | $890.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| MCS Life | $923.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| Medicare | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| MMM | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| MMM Vital | $710.85 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| Panamerican Life | $734.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| PMC | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| Tricare | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| Triple S Salud | $900.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| Triple S Vital | $739.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| Triple S Advantage | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| Negotiated Minimum Charge | $710.85 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| Negotiated Maximum Charge | $1,300.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| Discounted Cash Price | $3,336.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
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