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New Hampshire 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
$0.12 / $2.15 / $3.57
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.08 / $0.13 / $0.13
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.16 / $0.20 / $0.26
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.12 / $0.12 / $0.13
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.13 / $0.13 / $0.13
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.13 / $0.13 / $0.13
Harvard Pilgrim
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.13 / $0.13 / $0.23
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.13 / $0.13 / $0.13
Well Sense
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.05 / $0.14 / $0.23