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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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