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Hydroxyzine Pamoate, Oral

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

Rates data updated July 2026.

Facilitymedian $2 · 10th–90th $0$50%10%10th90th$2Professionalmedian $0 · 10th–90th $0$30%20%10th90th$0$0.1$0.2$1.0$5.0$20.0$100.0

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
$0.13
Median
$1.10
Typical High
$3.16
Aetna
Setting
Professional
Modifier
Global
Typical Low
$0.12
Median
$0.12
Typical High
$0.13
Asuris Northwest Health
Setting
Facility
Modifier
Global
Typical Low
$0.49
Median
$0.49
Typical High
$0.49
Asuris Northwest Health
Setting
Professional
Modifier
Global
Typical Low
$0.49
Median
$0.49
Typical High
$0.49
Cigna
Setting
Facility
Modifier
Global
Typical Low
$0.13
Median
$0.24
Typical High
$0.26
Cigna
Setting
Professional
Modifier
Global
Typical Low
$0.13
Median
$0.13
Typical High
$0.13
Kaiser Permanente
Setting
Facility
Modifier
Global
Typical Low
$0.04
Median
$2.95
Typical High
$5.13
Kaiser Permanente
Setting
Professional
Modifier
Global
Typical Low
$0.04
Median
$2.88
Typical High
$5.01
Molina
Setting
Professional
Modifier
Global
Typical Low
$32.36
Median
$33.11
Typical High
$75.86
Premera BCBS
Setting
Facility
Modifier
Global
Typical Low
$0.10
Median
$0.10
Typical High
$0.10
Premera BCBS
Setting
Professional
Modifier
Global
Typical Low
$0.10
Median
$0.10
Typical High
$0.10
Regence BlueShield
Setting
Facility
Modifier
Global
Typical Low
$0.49
Median
$0.49
Typical High
$0.49
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$0.49
Median
$0.49
Typical High
$0.49
United
Setting
Facility
Modifier
Global
Typical Low
$0.08
Median
$0.13
Typical High
$4.68
United
Setting
Professional
Modifier
Global
Typical Low
$0.13
Median
$0.13
Typical High
$0.13
Wellpoint
Setting
Professional
Modifier
Global
Typical Low
$0.10
Median
$0.10
Typical High
$0.10