Chemotherapy Drug Infusion
| DETAIL FOR SERVICES: | Facility Fee | Drugs | Physician Services |
| 2020 CPT/HCPCS Primary Code | Q0084 | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| Negotiated Private Fee | $625.00 | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| Prossam | $500.00 | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| Champva | Ambulatory Payment classification (APC) | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| First Medical | $172.00 | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| First Medical Vital | $144.90 | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| Plan de Salud Menonita | $113.00 | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| Menonita Vital | $144.00 | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| Humana Gold Plus / Gold Choice | Ambulatory Payment classification (APC) | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| Humana | $162.00 | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| Mapfre | $173.00 | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| Mcsclassicare | $164.00 | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| MCS Life | $164.00 | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| Medicare | Ambulatory Payment classification (APC) | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| MMM | $135.00 | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| MMM Vital | $144.90 | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| Panamerican Life | $120.00 | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| PMC | $135.00 | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| Tricare | Ambulatory Payment classification (APC) | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| Triple S Salud | $106.00 | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| Triple S Vital | $145.00 | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| Triple S Advantage | Ambulatory Payment classification (APC) | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| Negotiated Minimum Charge | $106.00 | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| Negotiated Maximum Charge | $500.00 | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
| Discounted Cash Price | $500.00 | Provided when treatment is required | Not provided by Hospital (may be billed separately) |
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