Amputation, leg, through tibia and fibula
| DETAIL FOR SERVICES: | Surgery Procedure | Hospital Stay (3 days) | Anesthesia | Physician Services |
| 2020 CPT/HCPCS Primary Code | 27880 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Negotiated Private Fee | $5,504.00 | $1,566.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
| Prossam | $3,420.00 | 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 | $1,950.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| First Medical Vital | $1,811.25 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Plan de Salud Menonita | $2,700.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Menonita Vital | $1,890.00 | 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 | $1,845.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Mapfre | $2,247.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Mcsclassicare | $2,811.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| MCS Life | $2.355.00 | 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 | $2,535.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| MMM Vital | $1,811.25 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Panamerican Life | $2,064.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| PMC | $2,535.00 | 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 | $2,400.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Triple S Vital | $1,890.00 | 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 | $1,811.25 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Negotiated Maximum Charge | $3,420.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) | |
| Discounted Cash Price | $4,403.20 | $1,252.80 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
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