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Michigan 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 / $0.15 / $3.48
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.10 / $0.12 / $0.13
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.19 / $0.39 / $0.74
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.02 / $0.02 / $0.03
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.70 / $1.97 / $2.66
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.70 / $1.87 / $3.87
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.13 / $0.13 / $0.46
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.12 / $0.20 / $2.38
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.10 / $0.14 / $0.16
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $75.00 / $100.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.13 / $0.13 / $0.14