go back

Washington 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
$0.13 / $1.09 / $7.37
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.12 / $0.13 / $0.13
Asuris Northwest Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.49 / $100.00 / $100.00
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.14 / $0.49 / $61.16
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.13 / $0.13 / $0.20
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.13 / $0.13 / $0.13
Kaiser Permanente
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.04 / $3.00 / $5.28
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.04 / $3.05 / $5.28
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $70.00 / $80.00
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$79,999.20 / $79,999.20 / $79,999.20
Premera BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.10 / $0.10 / $0.10
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.09 / $0.10 / $0.12
Regence BlueShield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.49 / $0.49 / $0.49
Regence BlueShield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.47 / $0.49 / $0.49
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$0.10 / $0.10 / $0.10
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.13 / $0.13 / $0.16
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.10 / $0.10 / $0.10