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Maryland rates for HCPCS Q0177

Hydroxyzine pamoate, 25 mg, oral, FDA-approved prescription antiemetic, for use as a complete therapeutic substitute for an IV antiemetic at the time of chemotherapy treatment, not to exceed a 48-hour dosage regimen

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.10 / $0.62 / $2.95
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.12 / $0.12 / $0.13
CareFirst
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.13 / $0.13 / $0.77
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$85.00 / $85.00 / $85.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.13 / $0.13 / $0.13
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.97 / $2.54 / $3.70
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.10 / $0.10 / $0.10
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.13 / $0.13 / $0.13
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.05 / $0.05 / $0.05