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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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4.34 / $5.80 / $526.86
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.12 / $0.12 / $0.13
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$47,000.00 / $77,999.99 / $94,999.99
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3.15 / $3.67 / $13.38
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.13 / $0.13 / $3.15
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.12 / $0.28 / $3.67
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.10 / $0.13 / $3.15
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.13 / $0.13 / $0.13