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Hydroxyzine Pamoate, Oral

Montana 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

Rates data updated July 2026.

Facilitymedian $1 · 10th–90th $0$50%20%10th90th$1Professionalmedian $0 · 10th–90th $0$30%50%10th90th$0$0.1$1.0$20.0$500.0$10.0K$200.0K

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$2.88
Median
$2.88
Typical High
$263.03
Aetna
Setting
Professional
Modifier
Global
Typical Low
$0.12
Median
$0.12
Typical High
$0.13
BCBS
Setting
Facility
Modifier
Global
Typical Low
$1.51
Median
$69,183.10
Typical High
$91,201.08
Cigna
Setting
Facility
Modifier
Global
Typical Low
$3.16
Median
$3.63
Typical High
$13.49
Cigna
Setting
Professional
Modifier
Global
Typical Low
$0.13
Median
$0.13
Typical High
$3.16
MountainHealth Co-op
Setting
Facility
Modifier
Global
Typical Low
$3.39
Median
$3.39
Typical High
$3.47
MountainHealth Co-op
Setting
Professional
Modifier
Global
Typical Low
$3.39
Median
$3.39
Typical High
$3.47
Providence
Setting
Facility
Modifier
Global
Typical Low
$0.12
Median
$0.19
Typical High
$2.40
Providence
Setting
Professional
Modifier
Global
Typical Low
$0.13
Median
$0.13
Typical High
$79.43
United
Setting
Professional
Modifier
Global
Typical Low
$0.13
Median
$0.13
Typical High
$0.13