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South Dakota 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
$0.15 / $0.15 / $0.15
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.12 / $0.13 / $0.15
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.38 / $0.38 / $0.47
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.11 / $0.19 / $0.40
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.10 / $0.10 / $61.16
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.43 / $3.27 / $4.59
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.09 / $2.91 / $4.09
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.26 / $0.26 / $0.26
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.13 / $0.13 / $0.14
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.10 / $0.10 / $0.10
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.10 / $0.10 / $0.10