Mastectomy Radical, including pectoal muscles, axillary lymph nodes
| DETAIL FOR SERVICES: | Surgery Procedure | Hospital Stay (4 days) | Anesthesia | Physician Services |
| 2020 CPT/HCPCS Primary Code | 19305 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Negotiated Private Fee | $3,837.00 | $2,088.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| Prossam | $4,560.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Champva | Diagnostic Related Group (DRG) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | First Medical | $2,600.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| First Medical Vital | $2,415.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Plan de Salud Menonita | $3,600.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Menonita Vital | $2,520.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Humana Gold Plus / Gold Choice | Diagnostic Related Group (DRG) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Humana | $2,460.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Mapfre | $2,996.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Mcsclassicare | $3,748.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| MCS Life | $3,140.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Medicare | Diagnostic Related Group (DRG) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| MMM | $5,653.70 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| MMM Vital | $3,915.14 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Panamerican Life | $2,752.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| PMC | $2,653.70 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Tricare | Diagnostic Related Group (DRG) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Triple S Salud | $3,200.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Triple S Vital | $2,520.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Triple S Advantage | Diagnostic Related Group (DRG) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Negotiated Minimum Charge | $2,415.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Negotiated Maximum Charge | $5,653.70 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Discounted Cash Price | $3,069.60 | $1,670.40 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
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